ST ANDREWS COMMUNITY HOSPITAL

Largo Road, St Andrews

University of St Andrews

STUDENT MEDICAL CONSENT FORM

This form must be completed and returned to the Practice BEFORE a Medical letter can be dictated by a GP. The charge of £35 must also be paid BEFORE the letter is done.

I ……………………………… consent to details from my medical records for the period and/or

consultation of………………………to ……………………………..being disclosed in way of a written

letter to Pro Dean of Medicine, University of St Andrews.

Signature: ………………………………………………… Date: ……………………………

Print name: ……………………………………………..... Date of birth: ………………………

Additional details to GP (please advise what information is needed): …………………………………

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For use by University of St Andrews – School of Medicine

Approved by: ......................................................	Date: ....................................................

Print name: .........................................................	Designation: .........................................

The invoice should be made out to ‘University of St Andrews’.

Reports and invoice should be sent to:

F.A.O. Pro Dean of Medicine, School of Medicine, Medical and Biological Sciences Building, North Haugh, KY16 9TF

Invoices to be paid from AMD0 MEDSTU