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Application for non-NHS doctors letters

Application for Non-NHS Doctors Letters
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

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