Only use this form if you have been asked to do so by the practice.
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Ladygate Lane Surgery
22 Ladygate Lane, Ruislip, HA4 7QU.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.