Patient request form for letters
If you request work that is not provided for under the terms of the NHS Primary Care Services contract, your GP may be happy to undertake such work for you, but, as this is a private service, you will incur a charge for completion of your request.
Please complete the form attached and either bring into the surgery reception or return via e-mail to firstname.lastname@example.org and our staff will contact you BEFORE the work is done to confirm that your GP is able to do the work requested and inform you of the charge payable.
If you wish to proceed we will usually commit to complete the work that you have requested within 30 days from that date. Should this not be possible, for example due to GP holidays or requests for a larger than normal piece of work, our staff will inform you when they contact you as above.
As soon as your GP has completed your request you will be contacted and we will arrange for it to be available for collection.
Patient Request Form