Non-NHS Work Request Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone
*
Date of Birth
*
/
Day
/
Month
Year
Date
NHS Number
Private work request
*
Please Select
Medical Examinations - Fee
Certificate of Fitness
Certificate of immunisation - £35
Private sick certificate for employer,
college etc. from £35.00
SR1 Form - Fee
Solicitors report (p/h)
Any simple letter to support Non–NHS information: fitness to fly,housing, social,social service from - £35
Basic letter - £50
Computer Printout (p/page, email free) - £1
Private prescription for travel aboard - £30
OFSTED report Invoice - £75
TPH2/204 - £135
Private appointment with Doctorr - £100
Private appointment with nurse - £50
Insurance Medical Reports - Fee
IGPR - £104.30
Insurance Company – supplementary reports - Fee
DVLA Paper report -£40
DVLA Medical Examination £85
Subject Access Request Free (A fee will apply is request is considered manifestly, unfounded or excessive) - £60
Local Authority - Fee
f Works and Pensions (DWP) - Fee
Disability living allowance forms DSA 1550 forms - Fee
Other
Request details
Organisation to whom the letter is to be addressed
Do you wish to see a copy of the letter before it is sent
*
Yes
No
Full name to whom the letter is to be addressed
*
Email address: Organisation to whom the letter is to be addressed
Collect from the practice (please bring an photo ID)
*
Yes
No
Additional Instructions
I hereby give permission for information contained within my medical records to be shared with the above person/organisationType a question
*
Yes
Signature
*
Submit
Should be Empty: