Private Services

To request a private service, please complete and submit this form.

Private Services Request

Private Services Request

Explanatory note:

This form should be used when a registered patient requests private services e.g. certificates of fact, private health insurance validation forms, fitness to travel/act/exercise, letters for housing, letters to employers/solicitors etc. The practice charges a fee according to recommended BMA rates for services that are not covered by the NHS. The current fees can be checked at reception or on our website. The fee covers the doctor’s time, administration and professional responsibility. You should allow 10 working days for completion.

For medico-legal reasons written consent is required prior to the release of information from a patients medical record. The form below, once completed, satisfactorily covers the medico-legal obligations of all concerned.

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
Please include postcode.
e.g. letter to school/employer
Be as specific as possible
Be as specific as possible, give name and full address

Patient's Guardian's Declaration