If you require a formal letter, or on behalf of a patient at the patient’s request, based on medical facts existing on your/their file please complete and sign this form.

Opinions which are not supported by, or do not necessarily follow from these facts may be disregarded.

Please note we will require 14 days or more to complete this request.

• 14 working days or more – the charge is £50

Selecting an option and signing the form commits you to paying the appropriate fee mentioned above.

Please note that the GP may not be in a position to write the letter if there is no evidence in your medical record to support your claim.