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.

If you are human, leave this field blank.

Section

GP Name:

Address:

Reason for request for example extension to work, reasonable adjustments, sickness absence etc:

Nature of Illness:

Date from:

Date to:

Give a brief description of the impact of this illness on studies for example on memory or motivation, concentration, anxiety, mobility, daily living etc.

I give my consent for St Clements Partnership to disclose information from my confidential medical records which is relevant to this request.

Yes

How would you like to receive your report?

I will collect from surgery

Please email it to me (Please note the report will be sent in an unsecured format to the email address you have provided)

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Medical Evidence Request

Section