Medical Evidence Request

This form should be used when you need to provide evidence to the University of an illness or inability to perform.

As this is not an NHS service there will be a fee of £10, please make sure your telephone number is entered so we can call you and take payment.

Please indicate if you would like to collect the report from the surgery or if you would like it emailed to you.

Medical Evidence Request

Medical Evidence Request

Section

I give my consent for St Clements Partnership to disclose information from my confidential medical records which is relevant to this request.
How would you like to receive your report?