Unity Health | COIAA request

Student details

Name *

Surname *

Date of birth *

Student Number *

Have you spoken to one of our clinicians about this illness? *

Yes, I have discussed this illness with a Unity Health clinician.

No, I have not discussed this illness with a Unity Health clinician.

You will need to discuss your illness with one of our clinicians. Please book an appointment via the NHS App, or speak to our reception team.

Start date *

End date

Describe the illness affecting your studies. *