Have you served in Armed Forces?

If you have ever served in the Armed Forces as a regular, or reserve, for at least one day please complete this form and submit to us.

People’s Views and Experiences of Veterans Mental and Physical Health Services Survey

Armed Forces Service

Patient's Details

Please use this date format: DD/MM/YYYY.
Gender *
Any responses we send will go to this email address.
Can we contact you by text?
Can we contact you by email?

Armed Forces service

Have you ever served in the Armed Forces as a regular or reserve for at least one day? *
Do you consent to the surgery obtaining your service medical records IF we feel that it would be of benefit to your care? If so please detail which force you served with: *
Please include postcode.
Please use this date format: DD/MM/YYYY.

What happens to my information?

Personal and medical information about patients registered at this practice are primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you.

We sometimes use accredited suppliers for our communication with you, for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols.

To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.