Hypothyroid Self Assessment

If you have been advised by the surgery to submit hypothyroid self assessment please use this form.

Last Updated: 23/10/2019

YOUR DETAILS

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Date of Birth Required
Required

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HYPOTHYROID SELF ASSESSMENT

Required
Required
Change in Weight: Required
Have you had your blood tested for thyroid in the last 9 months? Required

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA

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