Patient Request Form

Complete this form if you would like to request a medical report, letter or form to be completed by your GP. Please note there will be a £20 minimum charge for this service, once you have submitted the request a member of staff will be in touch with the amount payable. If you should cancel the request at any time there will be a £10 admin charge payable.

Last Updated: 15/07/2022

Patient details

Title *

Surname *

Forename *

Telephone Number *

DOB *

Address *

Requester details

Requester name (if different to above)

Request details

If your request is for a support letter or medical report please include as much information as possible to help your GP locate and supply the information you need. If you require the information following a request from someone else/a company please provide us with this information and if possible a copy of the request.

Type of request *

Description of your request *

Declaration

By submitting this form I agree to collect the document and meet the reasonable charges made for this service at that time. I understand that when I wish to collect the completed form that I must bring a copy of this form with me, along with photo ID. I understand that if I am not the patient mentioned above and I am requesting this information on their behalf, that the patient will be contacted for authorisation and that the patient will have to collect the information unless otherwise agreed with the patient.

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Patient Request Form

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