Test Results Request Form Are you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) About YouYour Name First Last First/Last Name(s) as appears on your passport.Postcode ZIP / Postal Code The one used to register with your GP.Your Date Of Birth DD slash MM slash YYYY Your date of birth is required to verify your identity.Sex Male Female Other As on your medical record.Your Phone Number:The practice may use this number to contact you about your request.Your Email This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.About the patientPatients Name First Last First/Last Name(s) as appears on your passport.Postcode ZIP / Postal Code The one used to register with your GP.Your Date Of Birth DD slash MM slash YYYY Your date of birth is required to verify your identity.Sex Male Female Other As on your medical record.About YouRelationship to PatientPlease Select…ParentGuardianSpouseCarerSonDaughterSiblingOtherPostcode ZIP / Postal Code Patients Name First Last Your Date Of Birth DD slash MM slash YYYY Your date of birth is required to verify your identity.Sex Male Female Other As on your medical record.Your Phone Number:The practice may use this number to contact you about your request.Your Email This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.Please continue completing the form belowTest Date: DD slash MM slash YYYY What test results are you waiting for? Email OptionalThis field is for validation purposes and should be left unchanged.
