Test Results Request

Please note, we request that you do not assume that a result is normal if we do not contact you. The surgery will contact you if there is a significant problem with your results, but please contact us for all results as the GP may have made some suggestions or advice based on your results even if there is not a significant problem.

Your details

First Name *

Last Name *

Email *

Date of birth *

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

Phone Number *

I confirm I am the patient *

Yes

I am the patient’s parent/guardian

I am authorised by the patient to request this information

If you are the parent of any children under the age of 11 you can request this information.

Information about your test

Test date *

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

What test results are you waiting for? *

Child details

First Name *

Last name *

Date of birth *

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

Test date *

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

What test results are you waiting for? *

I am not the patient

If you are not the patient, and you have not been given authority to access that patient records then we are unable to provide you with this information.

I am authorised by the patient to request this information

Please provide the details of the patient.

First name *

Surname *

Date of birth *

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

Date of Test *

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

What tests results are you waiting for? *

I confirm that I have the patient’s permission to obtain this information and we have a signed mandate provided by the patient authorising you to receive this information. We will contact you if we have any queries.

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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.

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

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Test Results Request

Your details

Information about your test

Child details

I am not the patient

I am authorised by the patient to request this information

Privacy Policy

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