Medical report and letters request

Section

Named GP (if known):

What do you require?

Please select the appropriate certificate(s) you require:

Private sick note

Holiday cancellation certificate (basic may vary)

If you require a private sick note, please provide your signature:

Why do you need this certificate?

Please select the appropriate letter:

Miscellaneous Letters

*

Please confirm that you are aware that if you require more information than detailed an additional charge for a new letter will be made.

What is the purpose of the letter?

By completing, you confirm that the letter provided will only be used for the reason stated in this field

Who should the letter be addressed to? (To complete the letter we will need the full address including postcode, department, and any appropriate names) *

Please provide name and address.

Reference Numbers:

Date required by:

Please use the format DD/MM/YYYY.

Standard letters cost £20 which is required in advance. However, an additional charge will be made if excess information is required or an appointment is required.

What format would you like this provided to you in:

Electronic copy via our website

Collect paper copy from practice

Paper copy posted to the recipient – additional £2.00 charge

Paper copy posted to yourself – additional £2.00 charge

Is there a specific clinician that you would like to provide the letter? Please note this may delay the letter if the clinician is unavailable:

Yes

No

Please specify:

Any medical conditions to be included:

Medications to be included:

Please provide as much detail for the requirement of the letter: *

Many thanks for this information, if we require anything further we will get in contact with yourself.

In the meantime we will put at invoice at the front desk for you to pay. If for any reason the clinician is unable to do the letter, we will contact you and issue a full refund.

We aim to complete these requests in 3 working days from the date of payment.

Please select the appropriate report(s) you require:

Employer’s report & opinion (without examination)

Employer’s report & opinion (with examination)

Sports medical report – with full medical

Life insurance report

Targeted reports (paid by insurance Co)

Foster carer 3 yearly update report (ID 15097)

UEA course OH questionnaire (pt) Non-Nursing

UEA Nursing OH questionnaire

Court of Protection/Power of Attorney Cert (Lasting Power of Attorney) – inc COP3

Please specify if you would like the following with the employer’s report & opinion (with examination):

Local Authority

Private

Please specify if you would like the following with the life insurance report:

With examination

Without examination

Deceased patient

Supplementary report

Please specify if you would like the following with the Court of Protection/Power of Attorney Certificate:

With examination (cert provided)

Without examination

Letter & examination to confirm mental capacity (require letter request from solicitor or formal body not request from relative)

Why do you need this report?

Please select the appropriate medical(s) you require:

Private medical insurance claim form & Pre-treatment form

Sickness/Accident insurance benefit claim form (paid by pt) & Basic Certs / Forms

Mini bus medical – 10 mins HCA & 20 mins Doctor

LGV & PCV driver certificate (paid for by patient) – 10 mins HCA & 20 mins with Doctor

Taxi driver certificate – with full medical (No urine sample required) 10 mins with HCA and 20 mins with Doctor

Elderly driver fitness certificate – with full medical

Racing driver fitness certificate – with full medical

Why do you need this medical?

Please specify:

Expedite Request

What is the department you need your referral/appointment expediting for?

Do you have any new symptoms?

Yes

No

Please specify:

Have your symptoms worsened?

Yes

No

Please specify how your symptoms have worsened:

Are your symptoms affecting your activities of daily living?

Yes

No

Due to answering no to the above questions, we are unable to process an expedite request as there has to be a clinical need to do so.

If you have provided medical reasons please be aware that we will process this request and send it onto the hospital, but it is the consultants at the hospital who make the final decision, so there is a chance this expedite request will be rejected.

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Section

Expedite Request