Ashley Non-NHS Doctor Statement Request Form

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.

I understand that it can take up to 21 days to process this document.

The statement will be addressed "To Whom It May Concern"

I understand that the initial charge for this statement is £45

The doctor may decline issuing the statement

The time spent producing your document will determine the final charge and your may receive a final invoice

Due to data protection, the practice will not send this document to an external organisation and the patient must organise collection in person.

ASHLEY Non-NHS services request: Doctors Statement Form

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ASHLEY Non-NHS services request: Doctors Statement Form

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