Dispute or Query Online Medical Record Entry Name First Last Date of birth DD slash MM slash YYYY PhoneEmail Details of Medical Record Entry you Wish to Dispute or QueryDate of Medical Record Entry MM slash DD slash YYYY Please explain what you wish to query or dispute within your medical records. Please provide as much information as possible to help us investgiate this for youPlease confirm you are aware that requests regarding entries into your medical record are non-urgent and will be progressed as quickly as possible, please note you should not contact our reception team about the form you have submitted or entries in your medical record and we will contact you when your query has been reviewed. I agree Optional