Other Private Services Request

This form is to request private work in the form of exemption for jury duty letters or To Whom It May Concern letters.

Last Updated: 16/02/2024

Your Details

Name *

Date of Birth *

Contact number *

Email Address *

Private Services Request

You must provide as much information as possible in the "Details of Request" section below including the reason for the letter, any relevant dates and any information you wish to be included in the body of the letter. Please note, there is a 5-7 day turnaround for these letters.

Examples of "To Whom It May Concern" letters; to state you are fit to participate in a private sporting event, a letter for an airline outlining your medical condition/medications or a letter for the local council/housing agency to support your application.

What type of Private Service Do you Require? *

Jury duty exemption letter

To Whom It May Concern letter

Details of Request *

Declaration

This form collects your personal data such as name, date of birth, email and other personal information. This declaration confirms you are registered with the Practice, you are happy for the Practice team to contact you and also to update your medical records.

By signing this declaration, you confirm that the information you have provided is accurate. You understand that there may be a fee of £30 for this work, payable prior to the work being completed. You confirm that you are aware there is a 5-7 day turnaround for private requests.

Are you submitting this form on behalf of someone else? *

Yes No

If you selected yes to question 2, please state your name and relationship to patient in the box provided below.

Signed *

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Other Private Services Request

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