To Whom It May Concerns Letter

If you require a formal letter, or on behalf of a patient at the patient’s request, based on medical facts existing on your/their file please complete and sign this form. Opinions which are not supported by, or do not necessarily follow from these facts may be disregarded. Please note we will require 14 days or more to complete this request. 14 working days or more – the charge is £50 Selecting an option and signing the form commits you to paying the appropriate fee mentioned above. Please note that the GP may not be in a position to write the letter if there is no evidence in your medical record to support your claim.

Are you completing this form on behalf of:

About you

Name
The one used to register with your GP.
DD slash MM slash YYYY
Sex
The practice may use this number to contact you about your request.
This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.
I need the letter by:
Why do you require this letter?
DD slash MM slash YYYY