You may use this form to send us information.

We welcome lifestyle information, home test results and vital statistics e.g. Blood Pressure, to keep your medical records up to date.

Please complete as many of the fields below as you can. Obviously these should be accurate and honest as we will enter them in your record

You must include a valid email address* so that we can notify you of receipt and/or a problem. This form is saved on our server and collected by email so is not quite 100% secure.

If you use your unique "AI code" found on your Repeat Request form (see example) you need only enter the first letter of your surname and forename.

Please use your TAB key or Mouse to navigate. Use "Today" button to enter today's date.
Surname
Forename
Date of Birth
Email :
AI code
Telephone
SMOKING STATUS
I have never smoked
I smoke    per day
I gave up smoking in (date). I used to smoke per day
Tick if you would like the surgery's Smoking Cessation Advisor to contact you
BLOOD PRESSURE
Reading
Units
Date
/
HEIGHT
Measurement
Units
Date
WEIGHT
Reading
Units
Date
PEAK FLOW
Reading
Meter Type (explanation)
Date
BLOOD SUGAR
Reading
Units
Date
CHOLESTEROL
Reading
Units
Date
To ensure you are not a spam bot. Please enter the first name of Dr Matthews      Thank you.
Thank you for using this form. *Warning some hotmail.com and gmail.com email addresses may not get through as they may be treated as spam use hhotmal or ggmail instead
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