Other Private Services Request

If you would like to request a letter/medical report, please use this form. All requests for letters/forms/medicals are non-NHS work and therefore chargeable. You will be informed of the fee prior to the work being completed. 

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Private Services Request

    What type of Private Service Do you Require?
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 11 March 2025
Page created: 02 November 2026