Request for a Private Letter or Form

 

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Personal Details
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May be used to identify you
 
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Reason for Request
Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx
 
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Confirmation
 
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Privacy Consent

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS.

Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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