Request for Non-NHS Work form

Please complete the form below if you would like to a request a letter from a clinician at the Practice or for a clinician to complete a form. The form will be submitted to the secretary team who will be in touch with the next steps.

Please be aware that if your query relates to non-NHS work then the following applies:

A fee may be charged to you – we will advise you of this before completing the work. Please refer to our Guide to Non-NHS Services.
NHS work will take a priority over non-NHS work and therefore we are unable to advise how long requests may take to complete.

Non-NHS Work

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your requirements

Would you like a clinician to write a letter for you (e.g. a support letter for housing, gym applications or support with studies etc.) or would you like a clinician to complete an existing form for you (e.g. a fostering form, HGV medical or insurance report etc.)?

What do you require from your clinician?

Write a letter

Complete an existing form

Letter request

Name of the person/organisation the letter needs to be addressed to

Postal address of the person/organisation the letter needs to be addressed to

Email address of the person/organisation the letter needs to be addressed to

A brief description of what the letter is needed for

0 of 250 max characters

Form completion request

In order for the clinician to complete the form please send this to the Practice for the attention of the Secretary Team. You can do this by dropping it into reception, sending it through the post to Cofton Medical Centre, 2 Robinsfield Drive, West Heath, Birmingham, B31 4TU or via email to [email protected]. Alternatively, upload in the field below.

Form Upload

Maximum file size: 10MB

A brief description of what the form is needed for

0 of 250 max characters

Privacy Policy

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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Cofton Medical Centre

Request for Non-NHS Work form

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Letter request

Form completion request

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