Non-NHS Services Request

Please tick the relevant boxes below. Accurate selection, will help avoid delays in processing your request.(Required)

Vaccinations (non-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. If related to a specific injury, please provide dates of injury/hospital attendance.(Required)

First Name(Required)

Last Name(Required)

Date of Birth(Required)

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)

Last Name(Required)

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)

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

Last Name

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

Applicant signature

Date

Patient Signature

Upload any supporting documents if required

Max. file size: 128 MB.

Name

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

COLINDALE MEDICAL CENTRE

Non-NHS Services Request