Document Upload Form | Heilendi Practice

Name

This field is for validation purposes and should be left unchanged.

What's your name?(Required)

First Last

What's your email?(Required)

What's your telephone number?(Required)

Date of birth(Required)

What are you uploading?

An image of your skin (Please make sure you have already made an appointment with one of our clinicians)

A document

File upload(Required)

Drop files here or

Max. file size: 50 MB.

Comments

Any further information you would like to provide.

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. 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.

Thank you for completing the form. After you click submit this will be sent to the surgery. If any further information is required we will let you know.