DVLA requested medical registration form

Please fill out the form using the information from the letter you received from the DVLA. In case of any difficulty please call reception on 01295 577927 (option 2) or email reception@oxmedgp.co.uk and we will try to assist you.

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First name

Surname name

Date of Birth DD/MM/YYYY

Phone number

Postcode

Address

DVLA Reference number (just enter the digits after the “M”, see example below)

Choose one option which best fits what the medical/medicals are related to:(required)

Drugs related

Alcohol related

I need a medical for both drugs and alcohol

Unsure

Who is paying for the medical(required)

DVLA

Myself

Unsure

I agree to allow OxMed Private General Practice to retain my details and understand that any personal data including anything regarding my health history will not be released to any 3rd party without my express permission save for the information requested by the DVLA and/or where required by law.