E Contact Private Work Request FORM

Last Updated: 23/08/2024

About you

In order to help us to assess whether we are able to assist with your request for a private letter please complete the following information. Return the completed form at reception

Please note private letters are subject to a minimum charge of £30. This is in line with recommended rates for non-NHS work, and can take up to 28 days from the date of payment received by the practice.

There are some situations which may require further assessment and if so you may be asked to attend an appointment. Although we will do our best to help please be aware completing this form does not guarantee that we will be able to assist with a letter. Each request will be considered individually and is at the discretion of your GP.

PLEASE NOTE:

No work can start on your Private Work Request until full payment has been received via Card payment one of our admin team will call you so payment can be taken over the telephone.

(We no longer accept Cash, Cheque or Bank transfer)

First name *

Surname *

Date of Birth *

NHS Number *

Home Telephone Number

Mobile Telephone Number *

CONTACT DETAILS FOR PERSON OR ORGANISATION LETTER IS TO:

What Private work are you requesting *

Organisation to whom the letter is to be addressed

Do you wish to see a copy of the letter before it is sent *

First name to whom the letter is to be addressed

Surname to whom the letter is to be addressed

Email Address: Organisation to whom the letter is to be addressed

Collect from Practice *

Name of GP that this request has been discussed with?

Full Request Details : *

I hereby give permission for information contained within my medical records to be shared with the above person/organisation *

Yes

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E Contact Private Work Request FORM

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