Private Requests for GP Services Please note there may be a minimum charge of £20.00 for this service Patient Name First Last Date of birth DD slash MM slash YYYY To whom should this letter be addressed (if known):Details to be included in letter:(please be as specific as you can – the more details the better)When is the letter required by Date: DD slash MM slash YYYY Please note that a minimum of twenty eight working days’ notice is required. Doctors receive numerous requests for private letters and forms, therefore we are unable to guarantee that your letter will be ready by the requested date)Patient ConsentConsent I consent to the release of medical information as detailed above.Signature
