Forms/Requests

We aim to make it easy for our patients to access the forms and services they need. Whether you require a repeat prescription, a referral letter, a medical certificate, or other administrative documents, you can submit your request through this page.

Please follow the instructions for each form to ensure your request is processed promptly.

Contraception Services

Contraception can be used to treat heavy periods and/or as part of hormone replacement therapy.

Joint Injections

Steroid injections can be a quick and effective treatment for joint pain.

Physio Services

Expert assessment and treatment for adults experiencing musculoskeletal issues

First Sick
Note

If you have been ill for more than 7 days, you will need a doctor’s certificate.

Sick Note Extension

If you have already had a Sick Note (Fit Note) for this illness your Doctor may not need to see you to issue an additional Sick Note.

Private
Letter

Requests can only be accepted from the patient, or the patients authorised representative.

Travel Vaccination

Complete the form 6 weeks before travel. If it is submitted with less than 6 weeks till travel, availability will be confirmed.

Medication Review

NOT For HRT Medication. Please read the instructions carefully before completing this form.

HRT Medication

This form should only be used by patients already receiving HRT.

Repeat Medication

Please use this form to request medication which is currently on your repeat medication list.

Non-Repeat Medication

Please only use this form to request medication which is not currently on your repeat medication list.

Update
Details

Please complete the form to update your contact details

Make a
Complaint

We make every effort to give the best service possible to everyone who attends our practice. To pursue a complaint, please complete the form.

Clinical Record Update

Ensure that you complete all steps of this form to successfully inform us of updates to your clinical record.

Access to Health Records

Please complete this form if you wish to access your personal data or request the practice restrict the processing of your data.

First Sick/Fit Note

You don't need to see a doctor if you have been ill for 7 days or less.

If you have been ill for 7 days or less, please fill in this Self-Certification Form.

If you have been ill for more than 7 days, you will need a doctor’s certificate.

These certificates are called ‘Fitness To Work’ Certificates. The doctor may call you or arrange an appointment.

Full Name

Date of Birth

Today's Date

Phone Number

Email Address

Home Address (including Postcode)

What is your job?

What is still preventing you from working?

Have you sought any help to return back to work?

First Date you were not at work due to this illness

Total Number of Days you Were Ill

Start Date of Your Sick/Fit Note

Describe Your Illness and Why You Need a Sick/Fit Note

No of Days/Weeks You Require Your Sick/Fit Note for

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.

Yes No

I consent to the practice contacting me by SMS.

Yes No

Request Sick/Fit Note Extension

If you’ve already received a Sick Note (Fit Note) for your condition, your doctor may not need to see you to provide another one.

Please fill out this form carefully. We’ll let you know when your Sick/Fit Note is ready to pick up or if you need to book an appointment.

To avoid delays, make sure to complete all parts of the form. Providing clear and detailed information helps your doctor review your request quickly and accurately.

Full Name

Date of Birth

Today's Date

Phone Number

Email Address

Home Address (including Postcode)

What is your job?

What is still preventing you from working?

Have you sought any help to return back to work?

First Date you were not at work due to this illness

Total Number of Days you Were Ill

Start Date of Your Sick/Fit Note

Describe Your Illness and Why You Need a Sick/Fit Note

No of Days/Weeks You Require Your Sick/Fit Note for

Yes No

I consent to the practice contacting me by SMS.

Yes No

Request for Private Letter

We can only accept requests from the patient or their authorised representative.

At our practice, our main focus is to care for patients who are unwell. Tasks like writing letters or reports (for things like insurance, adoption, fostering, driving (DVLA), housing, benefits appeals, schools, health clubs, or employers) are not part of our NHS GP contract.

When we provide these reports, they are considered a private service and are completed by our GPs outside of their regular NHS hours. These services usually have a fee, which we base on guidance from the British Medical Association for private fees.

View our Fees

If there’s a fee for your request, payment can be made (cash only) at the reception desk and you will be issued a receipt once paid.

Please allow up to 28 days for us to complete your request and the final document will need to be collected from the surgery.

Thank you for understanding, and we’re here to help with any questions!

Full Name

Date of Birth

Phone Number

Email Address

Home Address (including Postcode)

What is your Ethnicity?

Reason for GP Private Letter/Report/Certificate Request (Practice Staff other than doctors or nurses will read this and there will be a charge for these requests).

To whom it may concern (Please provide more detail below) For School or University (Please provide more detail below) For Local Authority (Please provide more detail below) Legal (Please provide more detail below) Other (Please provide more detail below)

Please provide a detailed reason for your request i.e dates, conditions, medication, impact on life and mental health.

Please attach all related documents.

I consent to the practice collecting and storing my data from this form.

Yes No

I consent to the practice contacting me by SMS.

Yes No

Access to Health Records Request

Please complete this form if you wish to access your personal data or request the practice restrict the processing of your data.

Please note that excessive requests will incur a charge.

Full Name

Date of Birth

Phone Number

Email Address

Home Address (including Postcode)

NHS Number (if known)

In order, to protect your information, we are unable to respond to a request unless we have confirmed your identity. Please provide one form of identification and one proof of address. If you are posting copies to us, please ensure these are appropriate certified, alternatively please attend the practice with original documents (acceptable documents listed below):

Documents that can be used as proof of Identity:

1. Current signed passport
2. Residence permit issued by the Home Office
3. EU or Swiss national identity photo-card
4. Valid UK photo-card driving licence (full or provisional)
5. Valid armed or police forces photographic identity card
6. Photographic disabled blue badge
7. Citizen card

What personal data are you requesting?

Please select which of the following applies

I am the patient named in section 1 (please proceed to section 3) I have a signed letter of authority to make this request I have parental responsibility for the patient who is under the age of 16 (please enclose a copy of proof of parental responsibility i.e. parental responsibility order issued by the Court or a copy of the Childs full birth certificate) - Please note that you do not have an automatic right to your child’s data and decisions will be made on the relevance of release of data to you. In the UK a child aged 13 years or older in most circumstances will be required to consent to the release of their data I have been appointed through a Lasting Power of Attorney to act on behalf of the patient (N.B. proof must be enclosed before the application can be processed i.e. a copy of the sealed document) Other Reasons (please outline)

Other Reason

If you are not requesting access to your own personal data, please provide the following information about you:

Full Name:

Address (including Postcode)

Date of Birth

Email Address

Phone Number

Relationship to person you're requesting data for:

PLEASE NOTE: If you are not requesting access to your own personal data, we are unable to respond to your request until we also receive the following:

Satisfactory confirmation of the identity of the person on whose behalf you are making this request. Please provide details outlined in section one.

A copy of your legal authority to make this request. This may be a signed letter of authority, a power of attorney document or other legal document confirming you are their legal representative.

What data are you requesting? Please provide as much detail as possible as to the data you are requesting, or actions relating to restriction, erasure, rectification, or objection. Please be as specific as possible as this will speed up the request process, include time periods and specific episodes of illness or treatment wherever possible.

I consent to the practice collecting and storing my data from this form.

Yes No

I consent to the practice contacting me by SMS.

Yes No

Forms/Requests

Contraception Services

Joint Injections

Physio Services

First Sick Note

Sick Note Extension

Private Letter

Travel Vaccination

Medication Review

HRT Medication

Repeat Medication

Non-Repeat Medication

Update Details

Make a Complaint

Clinical Record Update

Access to Health Records

Request Booking for Contraception

Please complete the form below to request a booking for contraception services and we will call you to book your appointment.

THIS FORM SHOULD NOT BE USED FOR ANY APPOINTMENTS OTHER THAN CONTRACEPTION SERVICES PLEASE.

Request a Joint Injection Booking

Please complete the form below to request a booking for joint injections and we will call you to book your appointment.

THIS FORM SHOULD NOT BE USED FOR ANY APPOINTMENTS OTHER THAN JOINT INJECTIONS PLEASE.

Request a Booking

Please complete the form below to request a booking for Physiotherapy and we will call you to book your appointment. Please note that we can only book one week in advance and the clinics are run in Woodlands Surgery and Riverside Health Centre.

First Sick/Fit Note

You don't need to see a doctor if you have been ill for 7 days or less.

Request Sick/Fit Note Extension

If you’ve already received a Sick Note (Fit Note) for your condition, your doctor may not need to see you to provide another one.

Request for Private Letter

We can only accept requests from the patient or their authorised representative.

Travel Vaccination Risk Assessment Form

Please complete the form at least 6 weeks prior to travelling.

Medication Review

Not For HRT Review - Please Use Menopause/HRT Form

HRT Medication Request

This form should only be used by patients already receiving HRT.

Repeat Medication Request

Please use this form to request medication which is currently on your repeat medication list.

Non-Repeat Medication Request Form

Please only use this form to request medication which is not currently on your repeat medication list.

Update your Contact Details

Please complete the form below to update your contact details.

Complaint Form

To pursue a complaint, please complete the form below

Clinical Record Update Form

Ensure that you complete all steps of this form to successfully inform us of updates to your clinical record.

Access to Health Records Request

Please complete this form if you wish to access your personal data or request the practice restrict the processing of your data.

First Sick
Note

Private
Letter

Update
Details

Make a
Complaint