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- Click ‘Get Form’ to open it in the editor.
- Begin with Part A: About You. Fill in your title, surname, first name(s), date of birth, driver number, address, telephone numbers (home and mobile), postcode, and email using BLOCK CAPITAL letters.
- Move to Part B: About Your GP and Your Consultant. Enter your GP’s name and address, consultant's name and address, their telephone numbers, and the dates you were last seen by them.
- In Part C, provide details of any other clinics you are attending. Include the clinic name, reason for attendance, date seen, and any relevant reference numbers.
- Proceed to the medical history section. Indicate any cardiovascular problems by ticking the relevant boxes and providing dates of diagnosis or treatment.
- Complete the medication section by listing current medications along with dosages and reasons for taking them.
- Review all sections carefully before signing the consent declaration at the end of the form.
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