Request for Private Letter or Medical report
Note: We can only provide a factual report based on your medical history.
First Name:
Surname:
Address:
Date of birth:
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Day
-
Month
Year
Date
Telephone number:
Email
example@example.com
Reason for medical report or letter:
What do you want to be written in the letter, please write briefly:
I here by give my consent to Belmont Medical Centre to provide a letter for me. This letter is not for legal purposes.
Date:
-
Day
-
Month
Year
Date
We require a minimum of 28 days to complete all the medical reports & private letters (this does not include Saturday/Sundays and Bank Holidays). This may increase during busy times of the year.
We do charge for private letters; Practice requires full payment in advance (Please ask the reception for the charges). Any request for more than one amendment of a medical report will incur a further payment of £50 charge.
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