Application for non-NHS doctors letters

Home Address:

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 will have to pay a fee of £20 for a short letter. Other documents may be considerably more and advice can be sought before any work is undertaken. The charge will need to be paid upon collection of the letter.
I am aware that the request does not have a specified timeframe in which my request can be completed.
I understand that any requests for letters for schools or requests for letters to support applications to Department of Work and Pensions (DWP) and Personal Independence Payments (PIP) in relation to benefit claims will not be undertaken.
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.

Signature: *

Date:

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

Your Name:

Phone Number:

Relationship to Patient:

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