Questionnaire - FasterDraft

Who is Sender?

Indicate full name of the sender:
Indicate contact mailing address of the sender:
Indicate the sender's contact email address:
Indicate the sender's contact phone number:
The sender creates this letter to request:
- their personal medical records/information
- their child's medical records/information
Select the date on which this letter is being signed and sent:

Who is Recipient?

Indicate the full name of a health organisation where this request is being sent:
Indicate registered mailing address of the health organisation:
Indicate the full name of a person who shall receive this letter on behalf of the health organisation:

Request Detais

The sender wants to request:
- full medical records
- specific medical information
Please list all specific medical information that the sender is requesting:
The requested information shall be provided back to the sender:
Does the sender wants to specify the purpose of such a request?
- No
- Yes
Please describe in detail the purpose of this request:

Miscellaneous

Select the sender's date of birth:
Provide the sender's NHS number:
What is the sender's relationship to the child?
- mother
- father
- legal guardian
Provide the name and date of issue of the document confirming the sender's relationship to the child:

!
The proof of relations may include:

– adoption certificate;
– child birth certificate;
– Special Guardianship Order;
– Child Arrangements Order etc.
Indicate the child's name whose medical records/information is being requested:
Indicate the child's date of birth:
Provide the child's NHS number:
Provide details of the child's proof of identity:

Do you want to add a signature?
- Yes
- No
Sender's signature:

Select a template's format:

PDF

DOCX

Back

You can skip answers for the questions.
Skipped answers will appear as blank part in the text of the final document. You can fill them in at later stage.

Back

Skip

You can skip answers for the questions.
Skipped answers will appear as blank part in the text of the final document. You can fill them in at later stage.

Who is Sender?

Indicate full name of the sender:

Indicate contact mailing address of the sender:

Indicate the sender's contact email address:

Indicate the sender's contact phone number:

The sender creates this letter to request:

Select the date on which this letter is being signed and sent:

Who is Recipient?

Indicate the full name of a health organisation where this request is being sent:

Indicate registered mailing address of the health organisation:

Indicate the full name of a person who shall receive this letter on behalf of the health organisation:

Request Detais

The sender wants to request:

Please list all specific medical information that the sender is requesting:

The requested information shall be provided back to the sender:

Does the sender wants to specify the purpose of such a request?

Please describe in detail the purpose of this request:

Miscellaneous

Select the sender's date of birth:

Provide the sender's NHS number:

What is the sender's relationship to the child?

Provide the name and date of issue of the document confirming the sender's relationship to the child:

Indicate the child's name whose medical records/information is being requested:

Indicate the child's date of birth:

Provide the child's NHS number:

Provide details of the child's proof of identity:

Do you want to add a signature?

Sender's signature:

Select a template's format: