Student Medical Evidence Request

There is a £25.00 charge for this service - Upon submitting your request you will be taken to the payment.

If you do not complete payment your request will be delayed.

If you are unsure which route to take and therefore what evidence is required, we recommend you discuss with Student Support in the first instance. Students in severe hardship can apply for financial support from the University Support Grant for this cost.

Why are you requesting a report?: *

Reasonable adjustments (including for exams) from Student Support ONLY

Special Considerations (when self-certification is not possible)

DSA Application ONLY

Other

Doctors Name: *

Surgery Name & Address: *

Consent

How are you completing this form: *

Personal Information

Full Name: *

Date of Birth: *

Email Address: *

Please double check you've entered the correct email address

Phone Number: *

Address: *

Nature of Illness: (Please write your request in English): *

Please give a brief description on the impact of this illness on studies for example on memory or motivational difficulties, anxiety or paranoia, mobility, daily living, etc.

Date from: *

Date to: *

Destination

For all completed requests, these will be either posted or sent via a link in a text message

Declaration

I understand that a fee is payable for the medical report as this is not an NHS Service. I am willing to pay the required fee. *

I agree to the release of medical information from records held by my GP. *

I understand that if I wish to see the report before it is sent, I must do so within 21 days otherwise the report will be sent to the person or service. *

I understand that a false claim of ill health used to influence the assessment of my University work will result in the imposition of penalties which may include the termination of my programme. *

Please upload one form of Photo ID (e.g.: Passport, Drivers Licence, etc.) - If you are uploading a copy of your Residence Permit, please ensure that both sides of this is included.: * (max: 5 MB)

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Signature: *

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

CONTACT DETAILS

Mulberry Surgery
7 St Denys Road
Southampton
Hampshire
SO17 2GN

Telephone: 023 8055 4161
Out-Of-Hours: 111

PRACTICE POLICIES

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PRACTICE POLICIES

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