Confidential information request form – Ages 13 to 19

We know at times it can be embarrassing asking for information on certain issues. To help you receive information you require in an easy and confidential manner please complete this form. You can also use the Practice website to request information.

How to obtain requested information?

You can either collect from the Lander Medical Practice reception desk in a sealed envelope, we can send it to an address of your choice or we can email it to you if you let us have your email address.

We will not automatically send any information to your home address unless you ask us to.

Confidential information request form

First Name *

Last Name *

Address

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Preferred Phone Number *

How would you like your information?

Collection from surgery

Post to address

What information would you like?

Privacy Policy

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.

Your consent *

I consent to the practice collecting and storing my data from this form.

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