Required field(s) are indicated by * Long Term Conditions Synchronisation Long Term Conditions Synchronisation If you are human, leave this field blank. Which surgery are you registered with? * Russell Street Surgery Burghfield Health Centre Coley Park Surgery Are you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) About you Your First Name(s): * First Name(s) as appears on your passport. Your Last Name: * Last Name(s) as appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * The practice may use this number to contact you about your request. Your Email: * This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you. Please continue completing the form below Named GP (if known): Which conditions have you been diagnosed with? * Submit