Application for non NHS doctors letters or forms

Home Address (including postcode):

Please select type of request:

Letter

Form

Medical/Examination

Name of person/organisation letter is to:

Address of person/organisation:

Reference Number (if applicable):

Brief summary of information/purpose of letter:

The doctor will only be able to include factually accurate information that is recorded in your medical records.

I have read the terms and conditions and understand that:

This application is for private work and may be rejected.
I may have to pay a deposit of £10 once submitting this application, if I decide I no longer require the letter/form/medical, but the GP has already assessed or started to complete the request, then this deposit is non-refundable. If the Practice refuses to complete the request the fee will be returned.
I understand that the full balance must be received before the completed request can be received if applicable.
I am aware that the request does not have a specified timeframe in which my request can be completed.
I will liaise with the practice if I need to the request to be completed sooner and am aware I may have to pay an additional charge.
I consent for my records to be accessed and for information about my medical history to be disclosed for the purposes of this letter/form/medical.

Signature: *

Date:

If completing on behalf of a patient, please confirm the following:

Your Name:

Phone Number:

Relationship to Patient:

Date Received:

Deposit Received:

Yes

No

Allocated to:

Appropriate Fee (£):

Price Accepted by Patient:

Yes

No

Completion/Collection Date:

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