Medica Report Request Form Medical Report Request Your DetailsNameDate of Birth Optional DD slash MM slash YYYY Phone Number OptionalEmail Address Named GP (if known) OptionalReportWhat type of medical report would you like? Occupational Health Advice Optional HGV/PSV Medicals Optional Taxi Medicals Optional Other Optional Why do you need this report?Consent I consent to the practice collecting and storing my data from this form. OptionalTHIS 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.