Request for medical evidence

Request for medical evidence
This form can be used to request a medical report which can be used to apply for special considerations.

It can also be used to request documentary evidence of a disability/condition so that the university can put in place reasonable adjustments (including for exams). You may also be able to use this for a DSA (Disabled Student’s Allowance) application.

If you are seeking documentary evidence for a new illness/condition/disability, you will need to have previously seen a GP about it.
Do you consent to your information being collected via this GDPR-compliant Jotform?*

Yes, I consentNo, I refuse consent
Without your consent, it is not possible to use this form to collect & transmit your data.

Please contact reception to obtain a hard copy of the request form instead. Thank you.

Why are you requesting a report?
Please select:*

Reasonable adjustments (including for exams)Special Considerations (when self-certification is not possible)Disabled Students Allowance applicationOther

Required Information
Nature of illness/condition/disability:*
Brief description of illness
Start date:*
End date:
(If ongoing, please state ongoing)
Which clinician did you speak to regarding this issue?
How does your illness/condition/disability affect your studies? If applying for special considerations, how did this affect you at the time of the assessment?*
Please provide a brief description of your illness on your studies

What should we do with your report?
What should we do with your report?*

COLLECTION - I will collect from the practiceEMAIL - Please send via email to:
Email destination for the report*
example@example.com

Email security
You have asked us to email your report to a given address.

We must inform you that email is not secure and there is a possibility that this method can be hacked or otherwise intercepted.
Are you still happy for us to email your report?

Yes, I acknowledge email is not secure, but still send it using this methodNo, I wish to collect the report instead

Reviewing your report
Do you wish to see your report before it is despatched?

No, just email it to the address givenYes, I wish to review my report before it is sent

Reviewing your report
You will have 21 days in which to review your report at reception.

To review the report, simply attend reception and ask to see a copy.

If you fail to review it within these 21 days, it will be sent to the email address you nominated anyway.

Payment
The provision of a medical report is not an NHS service.

Therefore the practice charges a fee of £25 to cover the administration time, doctor time and insurance needed for such independent services.
prevnext( X )
Medical Evidence Report
£25.00

Total

£0.00
Declaration
1. I understand that a fee is payable for the medical report as this is not an NHS service. I am willing to pay the required fee.

2. I agree to the release of medical information from records held by my GP.

3. I understand the completion time for reports is 10 working days from the date the form is received at the Surgery.

4. I understand that if I wish to see the report before it is sent, I must do so within 21 days otherwise the report will be sent.

5. I understand that a false claim of ill health used to influence the assessment of my University work will result in the imposition of penalties which may include termination of my programme.
Please select:*

I understand & agree with the above statementsI do not agree with the above statements
Signature*

Clear
If you do not agree with the above statements, we are unable to undertake this work for you.
Should be Empty:

Your details