DR SUZANNE WATERERPHONE: 0131 557 5545
DR SAMUEL WATT
DR GILLIAN MCGOVERN
DR IONA MACCALLUM
FAX: 0131 524 1188
9 BRUNTON PLACE
EDINBURGH
EH7 5EG
Request for non-NHS Service
Dear Patient,
You have requested that a doctor at this practice provides a service that is not part of core NHS work. Examples are providing letters for holiday cancellation, medical letters for gyms and health clubs, and insurance reports.
These services are not covered by the National Health Service and thus attract a fee.
In order for us to proceed with your request please complete the section below. Once you have completed the form, the doctor will look at your request and decide what the fee will be. Once you have agreed and paid the fee, the doctor will complete your request.
PLEASE ALLOW A MINIMUM OF TWO WEEKS FOR THIS WORK TO BE COMPLETED
Name……………………………………….Telephone………………………
Address……………………………………….
……………………………………….Mobile………………………
……………………………………….
……………………………………….
Date of birth……………………………………….
Full description of what is required (please attach any forms that need completing)
………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………
Admin Only
Date received……………………..
Fee as per sheet£…………………… or Fee from GP£……………………..
Date Patient Contacted……………………..
Patient Fee AgreementY / N
Date Fee Paid……………………..
Receipt Number……………………...
Brunton Place Surgery
Fess for Non-NHS Services
1stSeptember 2015
Fit to fly in pregnancy letter………………………………….. £20.00
Fitness to exercise letter (for gym)……………………………£35.00
Holiday insurance cancellation letter…………………………£20.00 - £50.00
Immunisation history………………………………………….£20.00
Medication for airline travel letter (fluids and needles only)…£20.00
Missed exam letter…………………………………………….£20.00
Photocopy of letters/records…………………………………..£1.00 per sheet
Private prescription……………………………………………£15.00
Private referral………………………………………………...£20.00
Private sick note……………………………………………….£20.00
Power of Attorney…………………………………………….£70.00
Access to records under Data Protection Act
Copy of medical records more than 5 pages…………………£50.00
Private Consultations
Consultation for private patients (10 min app)………………£50.00
Consultation for private patient with prescription (10 min appt)£65.00
Private Medical Examinations and Reports
The rate for non-NHS services is £220.00 per hour pro rata; this includes preparation of reports from records, consultations with or without examination or medical examinations.
Reports include:
Insurance claim forms
GPR (GP report for insurance company)
Employer’s report and opinion
Solicitors’ reports
Reports or letters requested by patients (if not named above)
Medical examinations include:
Pre-employment medical
LGV (HGV/bus) medical – DVLA form
Taxi medical – Council form
Sports/ diving medical
Fostering medical