Private Report Request Form

Free Of Charge Forms

Council Tax Discount Forms (not for letter), Universal Credit Form, PIP Form– give brief summary (first application, DSA Form– Disability Support Allowance, Sure Start Maternity Form, Certification Form (template on emis)

Forms We Are Unable To Do

ATTENDANCE ALLOWANCE FOR STATE PENSIONER, LONG STAY VISA REQUIREMENT (PT TO DO PRIVATELY), Doctors no longer SIGN PASSPORT or Visa application form

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Please tick the box that applies to your request

Private Letter

Requesting your Records

Why do you need this letter & additional notes?

Please select if one following private letters request:

To whom it may concern letters (for 1 problem) £25.00

To whom it may concern letters (for more than 1 problem) £50.00

To whom it may concern letters which include a medical opinion Patient £70.00

Please select if one following Blue Badge & Freedom Pass schemes:

Letter of Appeal against adverse decision £25

Please select if one following Certificates & Forms:

Letter re fitness to exercise/ travel/ housing/ To whom it may concern £25.00

Private Sick Note (any sick note within 7 days is private) £30.00

Provident Association claim form (e.g. PPP) £25.00

Fitness for sport/ school/ university etc. £30.00

Health Certificate to attend university, college, teacher & nurses £70.00

PADI Fitness for Driving Medical Statement £45.00

Please select if one following Driving related forms:

Fit to Drive medicals (all cab/ taxi/ bus HGV medicals – Form TPH/204) £100.00

Report no examination (20 to 30 mins) £60.00

Extract from records (15 mins) £67.00

Seat belt exemption £70.00

Elderly driver certificates £70.00

PCV / LGV driver £90.50

Please select if one following Employment related forms:

Full medical with report or certificate (private/ insurance – 45 mins) £169.50

Report without examination (private/ insurance – 30 mins) £133.00

Report Pro forma (20 mins) £89.50

Medical report requested by solicitors £90.00

Extract from records (no examination or opinion – 15 mins) £67.00

Certificate of Incapacity – can include at the GP’s discretion – a To Whom it may concern letter with brief details of a patient’s medical condition £25.00

Please select if one following Fitness for sport / school / university related forms:

Examination and report £132.00

Extract from records (15 mins) £67.00

Short Certificate of Incapacity £30.00

Please select if one following Insurance (sickness) forms:

Examination and report/ Fostering/Adoption Care £169.10

Extract from records (15 mins) £67.00

Insurance Claim form completion £45.00

Please select if one following Insurance (accident) forms:

Examination and report £148

Report without examination (Medical opinion to be included at GP’s discretion) £133

Report on pro forma (20 mins) £89.50

Extract from records £67.00

Short certificate £30.00

Please select if one of the following Life Assurance requests:

GP examination own patient £92.50

GP report no examination £84.00

GP supplementary report £21.50

Certificate of Existence £15.00

Please select if one of the following Private Medical Examinations and Reports:

Full examination with report or certificate £141.10

Report no examination Private (30 mins) £133.00

Report on Pro forma (20 mins) £89.50

Travel Abroad

Pregnant Woman’s Medical Certificate Attesting Fitness to Fly – TO STATE IF THEIR IN GOOD HEALT, TO INDICATE BABY’S EXPECTED DATE OF BIRTH, NEED TO BRING MIDWIFE BOOK, DATE OF FLIGHT AND BACK AND HOW MANY WEEKS PREGNANT AND DATE WHEN SHE LAST SAW HER MIDWIFE. £15.00

Fitness to travel certificate – pre-existing illness £27.00

Holiday cancellation simple certificate £15.00

Holiday cancellation insurance claim £26.00

Simple letter detailing prescription medicines with Surgery Stamp £10.00

Firearm/Shotgun Certificate £50.00

Proof of Registration £10.00

Irish Pension (book f2f appt) £10.00

Home Office Waiver for Language and Life in the UK £70.00

File Upload (optional)

Maximum file size: 10MB

Privacy Policy

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.

I consent to the practice collecting and storing my data from this form.

Captcha

If you are human, leave this field blank.