Application for Non-NHS Doctors Letters or Forms


Please select type of request:

Details of Letter

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

Patient Declaration

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.

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

For Office Use Only

Deposit Received:
Price Accepted by Patient: