Application for Non-NHS Doctors Letters or Forms

You have requested that the practice provides you with a private letter or form. In order to arrange for the appropriate work to be carried out please complete this application form.

Private letters and forms are not part of the Practice’s NHS contract and therefore there are charges for this work, there may also be a delay in processing the request as NHS contract work will take priority. For this reason, we cannot provide a specified time in which it will be completed. The GP is within their rights to reject this private work, should it be

If you require a quick response, please note the practice will endeavor to complete the request promptly; this may incur an additional charge which will be discussed with you.

Your application will be acknowledged and the charges will be agreed before work commences.

You will be required to place a deposit of £10 (if you require a To Whom It May Concern letter) before the application will be processed this is a non-refundable deposit (unless the work is rejected by the practice). Please bring this with you when handing in the application. Please note, the practice only accepts cash or cheque payments.

If applicable, the remaining balance will need to be paid before the request can be handed over, if you wish to read the information before paying the full balance this can be arranged.

Application for Non-NHS Doctors Letters or Forms

Patient Details

Any responses will be sent to this email address.
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 cover note of the application 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:

For Office Use Only

Deposit Received:
Price Accepted by Patient: