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Medical Insurance Report Query?

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Medical Report & Records Query

This form is for professionals only. Required fields are marked with an asterisk (*).

Contact Name*

Date

Company Name*

Policy Number

Company email address for response*

Please complete the patient details below

Patient First Name*

Patient Surname*

Date of Birth*

House Name/Number*

Town*

Patient Telephone Number*

Street*

Postcode*

Please note that if your enquiry is relating to a new medical insurance report or claim, we require mandatory documentation submitted on company headed paper, supporting this form, to allow us to process your enquiry, failure to do so will mean we are unable to process this enquiry further and you will not receive a response

How can we assist you?*

*Please make sure all Mandatory fields have been completed

Has the insurance report been paid for?*

Yes

if yes please add payment details and date paid

Payment Details

Date

*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

Please type the characters*

This helps us prevent spam, thank you.

This field should be left blank

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Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

Other forms available

Register as Patient

Please visit our Patient Registration page and fill in the health questionnaire to register as a patient at Teldoc.

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Please visit our Change of Name Form to update your details

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