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Decline Your Medical Review

Your Details

I Would Like to Decline My Review this Year *  
If you change your mind, please contact the surgery and we will arrange for you to have your review
I take full responsibility for declining my review and the impact this could have on my health *  

How do we contact you?

Please confirm if you would be happy for the surgery to communicate with you by e-mail  
I would like to receive text reminders  
Fields marked with an asterisk (*) are mandatory