Information Request Form

INFORMATION REQUEST FORM (UK Only)

If you wish to request more information about any of the topics on our web site, please fill in the form Download and send this form to us. We are only able to supply information to within the UK. If you would prefer, you can complete this page and press submit, to email your request to us.

Any information you provide will only be used to supply you with the information you require. It will not be passed onto anyone else.

Name and Address

Title:

Initial:

Surname:

Address:

Postcode:

Telephone:

E-mail:
(If applicable)

Information You Require:

Please tick the appropriate boxes to indicate the information you would like us to send you and give further information where requested.

Information on a specific medical condition.
Please give details of which condition(s) you require information on:

Information about local (Rotherham) or national self-help or support groups.
Please give details of which condition(s) you require information on:

Information about healthy living, eg healthy eating, smoking, alcohol, drug and solvent abuse.
Please give details of what is required:

Details of Rotherham GPs.
Please indicate which area of Rotherham:

Details of Rotherham dentists.
Please indicate which area(s) of Rotherham:

Details of any other health services within Rotherham.
Please give details of the required service(s):

How to register with a GP

How to change your GP.

Waiting times for local (South Yorkshire area) hospitals.

Please give details of Consultant or Department:

How to obtain a new medical card

Please send me an HC1 Form - Claim for Help with NHS Costs

Please send me an HC11 Form - Are You Entitled to Help with Health Costs

Please send me a Medical Exemption Form (FP92A)

Please send me a Prepayment Application Form

Any other health related information: Please supply details of what is required: