e-med INFORMATION REQUEST FORM Please fill out the following form with a description of what information you would like. Name * DOB (dd/mm/yyyy) * Postal Address  Post Code   E-mail Address * Please note: AOL e-mail account holders will need to check their Spam folders for communications from e-med. Phone   How did you hear about us ? What specific information is required? * N.B * Indicates complusory information Please note that none of your personal details will be sent to any third party under any circumstances without your specific permission.