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Felmores Medical Centre

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Friends and Family Survey
Changes To Your Inhaler
How Can We Help?
New Patients
Appointments
Prescriptions
Sick Notes
Health Advice
Practice Services

Opening Hours
Contact Us
Our Team
Patient Record
Practice News

Private Services Request Form

Please use this form for Medical Reports or other Private Requests that require a letter from a GP. Please allow up to 28 days for the request to be processed.

Last Updated: 15/10/2021

Your Details

Name *

Date of Birth *

Address *

Phone Number *

Email Address

Private Services Request

What type of service do you require? *

Army

DVLA

Education

Fitness to Travel/Participate

Gun Licence

Holiday Cancellation

Housing

Life Insurance

Passport/Driving Licence

Private Sick Note

Solicitors and Courts

Other

Please include any other details about your request *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing my data from this form.

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