Ash Trees Surgery - Patient Request form for Letters

If you request work that is not provided for under the terms of the NHS GP 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 below 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 28 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 at the branch surgery of your choice.

Please note: The letter will not be released until payment is made.

Name*

First NameLast Name

Contact Telephone Number:*

Date of Birth:*

Address:*

Street Address

Street Address Line 2

CityCounty

Post Code

Please explain briefly what you want the letter to contain and the reason for your request:*

Signature*

Date*

Do you have any special requirements, eg: wish to discuss with your GP first, wish to ask someone other than your usual GP, etc?

PLEASE FILL OUT THIS FORM AND CLICK THE SUBMIT BUTTON BELOW AND IT WILL BE SENT ELECTRONICALLY TO THE SURGERY.

ALTERNATIVELY YOU CAN DOWNLOAD THE FORM HERE AND LEAVE IT AT RECEPTION AT ANY OF OUR SURGERIES OR POST TO: THE FINANCE TEAM, ASH TREES SURGERY, MARKET ST, CARNFORTH, LANCASHIRE, LA5 9JU.

If you have any questions at any stage, please call 01524 720000 and ask to speak to Emma.