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Request To Disclose Medical Records

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Request To Disclose Medical Records

Full Name *

Address Line 1 *

Address Line 2

Town/City *

Postcode *

GP Address *

GP Email Address *

*

I agree to disclose all medical records in respect of myself

*

I consent to the full medical records being disclosed to Christchurch Clinics, 132 High Street, Braintree, Essex, CM7 1LB

Signature *

Date

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