Secretaries:To Whom it May Concern Letter Requests

Please complete this form if you require a letter from your doctor. Please note we will review every request but it is up to the doctors discretion on whether to complete a letter. Ensure you detail as much key information in order to assist our team.

As this service is not covered by the NHS, this is charged at £28.50 which must be paid before we can carry out the service. Payment can be made by cash or card at the surgery. We will contact you via a text message to let you know the outcome of your request.

Please do not write any symptom queries on this form. Any symptom queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926331401. We will start to process your form by the next working day but it will take up to 14 working days to complete. Please DO NOT call before 14 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Who would you like your letter addressed to?

Reason for letter request?

I confirm I am happy to be contacted by the surgery (text or call) on the mobile number provided if deemed necessary and that the information given in this form is accurate.

I am happy to pay £28.50 upfront if the letter request is approved. Our admin team will contact you to process payment.

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 Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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.