Consent to Request Additional Clinical Information

Please fill in the form below and submit it. 

A copy of this form will be sent to the email address you submit.

Sometimes it is necessary to write to another healthcare professional – usually your GP or a hospital specialist - to request more information regarding your condition, in order that any recommendations made to your employer are appropriate. Any such request will be made in accordance with the GMC guidance on medical confidentiality (2017), and any associated information will be handled in accordance with The Data Protection Act (2018).
to Proteus Occupational Medicine Services writing to the healthcare professional named below, requesting additional medical information regarding my condition, as part of the occupational health management of my case.
Address of Healthcare Professional(Required)
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Date(Required)