Request Non-NHS Private Work

Non-NHS Private Work Request Form

Private work requested

Please tick the relevant boxes below. The more specific you can be, the easier it is for us to quickly respond to your request. Record in respect of treatment for: (e.g., leg injury following a car accident).(Required)

I am applying for DVLA, Cab, HGV £135.00

• DVLA Additional Information £40.00

Firearms Licence - (Depending On Level Of Work Required) Starting From £50

Fitness To Fly - Pregnant Woman £30.00

Fitness To Travel Short Certificate - Existing Health Conditions £30.00

Fitness To Travel Exam & Report £70.00

Freedom From Infection - Travel, School, Employment £45.00

Insurance Claim Form Completion - (Depending On Level Of Detail) Starting From £40

Private Prescription £20.00

Private Sick Note £20.00

Private Letter Relating To Flights / Travel With Medicines £30.00

Other Private Letters - (Depending On Level Of Detail) Starting From £40

Private Letter For Absence from Work £50.00

Private Letter For School, University Exams £60.00

Private Letter - Full Medical History £75.00

Registration Letter For An Individual Person £30.00

Registration Letter For More Than One Person (i.e. Family Member / Household) £45.00

Travel Vaccination Certificate £20.00

Travel Cancellation £30.00

Vaccinations not provided by the NHS

Hepatitis B (Travel) - 3 Doses £170.00

Japanese Encephalitis - 2 Doses £190.00

Rabies - 3 Doses £185.00

Meningitis ACWY £70.00

Tick Borne Encephalitis - 3 Doses £140.00

Please specify the reason for requesting a letter(Required)

First Name(Required)

First

Last Name(Required)

Last

Date of Birth(Required)

Day12345678910111213141516171819202122232425262728293031

Month123456789101112

Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Address(Required)

Street Address City Postcode

Phone Number(Required)

Email(Required)

If request is for more than one person then please list the above details for each additional person

Are you the Patient(Required)

Yes

No

Please complete if you are requesting access on behalf of the above-named patient

First Name(Required)

First

Last Name(Required)

Last

Phone Number(Required)

Email(Required)

Address(Required)

Street Address City Postcode

Relationship to the patient(Required)

Proof of identity   Patients will be asked to provide 2 forms of identification one of which must be photographic identification. Please speak to reception if you are unable to provide this. Countersignature will be accepted only in exceptional circumstances.  

Consent for children   If a child aged 13 or over has “sufficient understanding and intelligence to enable him/her to understand fully what is proposed” (known as Gillick Competence), then she/he will be competent to give consent for him/herself. They may wish a parent to countersign as well. Young people aged 16 and 17 are legally competent and may therefore sign this consent form for themselves but may wish a parent to countersign as well. If the child is under 18 and not able to give consent for him/herself, someone with parental responsibility may do so on his/her behalf by signing this form below.

Timeframe for responding to requests   In accordance with the UK GDPR, patients are entitled to receive a response within the maximum given time frame of one calendar month from the date of submission of the request. To ensure full compliance regarding Private Work, this organisation will adhere to the guidance provided in the UK GDPR. In the case of complex or multiple requests, the data controller may extend the response time by a period of two months. In such instances, the applicant must be informed in the first month and the reasons for the extension given. Should the request involve a large amount of information, the data controller will ask the data subject to specify what data they require before responding to the request. Data controllers are permitted to “stop the clock” in relation to the response time until clarification is received. Incomplete applications will be returned; therefore, please ensure you have the correct documentation before returning the form. You will be telephoned when the letter / document is ready for collection or posting.

No Refund Policy   Please be advised that Colindale Medical Centre has a no refund policy for such items of work. The practice takes significant time and effort to process & action your request outside of their usual NHS duties. This time is accounted for in the fees, and therefore, once the practice starts any work on your request, a refund cannot be issued. By submitting a request for Private (Non-NHS) services you are confirming the nature of the work you require, and that you accept the non-refund policy.

Date(Required)

Day12345678910111213141516171819202122232425262728293031

Month123456789101112

Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Patient Signature(Required)

I confirm that I give permission for the Organisation / Parent to communicate with the person identified above regarding my medical records

Applicant Signature(Required)

Patient Signature(Required)

Countersignature

This is to be completed by someone (other than a member of your family) who can vouch for your identity. This section may be completed if proof of identity cannot be fulfilled.

First Name

First

Last Name

Last

Phone Number

Email

Address

Street Address City Postcode

Relationship to Patient

I certify that the applicant is known to me personally and that I have witnessed the signing of the above declaration. I am happy to be contacted if further information is required to support the identity of the applicant as required.

Date

Day12345678910111213141516171819202122232425262728293031

Month123456789101112

Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Applicant signature

Date

Day12345678910111213141516171819202122232425262728293031

Month123456789101112

Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Patient Signature

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Name

This field is for validation purposes and should be left unchanged.