Benefits medical report request form
Please complete this form to assist the surgery with your request for a medical report/examination
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ONLY complete this form IF you have completed payment AND been given a REFERENCE by the surgery. Failure to complete payment AND include reference will result in your entry not being processed and discarded
REFERENCE given by the surgery *
please include the reference number provided by the surgery to be used. If you have not been given one please contact the surgery BEFORE completing this form
FEE for report *
Please include below the fee AGREED with the surgery and that you have PAID to the surgery. It usually takes up to 4 WEEKS from date of receipt of full payment & completed form. If a medical examination is required within 1 WEEK, the charge may be double. If a different amount was agreed please click OTHER and type the amount
HOW was the fee paid?
Please include details how the fee was paid. If DIFFERENT to the options below choose OTHER and free text
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DATE of fee paid *
Please include the date by which the fee was paid
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TIME FRAME for report *
Please include the time frame agreed by the surgery for this form. If different date was AGREED to the list below please choose OTHER and free text the date
YOUR DETAILS
Please include your latest personal details so that we can contact you if necessary. Failure to do so will result in the surgery not processing and disposing of your submission
Your Full Name *
Your Date of Birth *
Please include your DOB in the form of dd/mm/yyyy i.e 01/01/1980
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Your MOBILE number *
In order to contact you we need your latest mobile number
Your EMAIL address *
In order to contact you or send you documents we require your email address
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