Request for Consent from a Private Healthcare Provider

First Name

Last Name

Date of Birth

Address

Postcode

We have recently received a letter from a private medical care provider asking for details of your health records. This is in relation to a mounjaro injection. Although they state that you have provided consent to provide this, they have not provided proof.

To ensure you are prescribed safely, we wish to forward a summary of your medical record to the company. This will consist of:

Name
Date of Birth
Address & Postcode
Past Medical History
Last 6 visits to practice
Current medications in the past 3 months

Do you provide consent for these to be forwarded to the company?

Yes

Please be advised that we will notify the company that you have declined consent.

If you are human, leave this field blank.