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Western Vale Family Practice

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My Health Online
Reception & Appointments
Health Advice & Self Help
Prescriptions & Admin Support
New Patients & Registration
COVID-19 Information
Travel Health Information

Home
Language
COVID-19 Information
Appointments
Health Advice & Support
Practice Policies
Contact Us

Private Services Request

Last Updated: 29/02/2024

Your Details

Name *

Date of Birth *

ContactNumber *

Email Address *

I consent to the Practice communicating via SMS Text Messaging and Email *

Yes

No

Private Services Request

What type of Private Service Do you Require? *

Letter from the Doctor

Private Sick Note

Fitness to Travel/Participate

Copy of Full Medical Records

Copy of Small Medical Records

Copy of Test Results

Holiday Cancellation Form

Other

Details of Request *

I understand a fee of AT LEAST £40 is payable in advance of this request being passed to a clinician. I agree to an invoice being sent to me by email. I understand my request will only be passed for action once payment has been received. *

Yes

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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This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

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