Request for To Who It May Concern Letter/Letter from GP

Section 1 – Patient Details

Surname

Maiden Name

First Name

Title

Date of Birth

Address

Postcode

Telephone Number

Section 2 – What information would you like to be included in the letter

Who is the letter for

What is the letter regardingIs the letter regarding a specific condition, if yes note what condition

Any additional comments or informationIf someone is collecting this on your behalf please enter their full name here

Is the letter routine or urgent?

The processing time starts once the cash fee has been paid

I understand that all completed letters are kept for three months, and if not collected in that time they will be destroyed.

I understand that payment for the letter is non-refundable.

Photo ID MUST be supplied on collection.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Prospect Surgery • Cleveland Health Centre, 20 Cleveland Square, Middlesbrough, TS1 2NX.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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