Request for Non-NHS Services Form Request for Non-NHS Services Your Request: Please can you consider completing the following work: (mark each box to confirm agreement) State your request here:I have been asked to request this report by: I have attached an additional letter detailing what information is requested and what I would like included.Max. file size: 50 MB.Consent I understand that without this, you may decline to undertake this work. I understand that you will only be able to include in your report information that is already on my medical record.Consent Priority option 100% surcharge OptionalWe will aim to complete this work within 2 weeksConsent I have paid the fee indicated. I understand that if the work is more complex, the fee will be more, and I agree to pay an additional fee before it is released.(Required)Consent Unless I selected the priority option, I understand that this work may take up to 4 weeks to complete.(Required)Consent I understand that there are circumstances where you may not be able to complete this work in the requested time frame due to emergencies or unforeseen circumstances or in rare cases at all. (Your fee will be refunded).(Required)Consent I understand that this report does not guarantee success in any application or appeal if used as support.(Required)Consent I agree that if I (or third parties on my behalf) make an appointment with a doctor to discuss a letter, I will pay an additional fee of £40 per fifteen minutes or part thereof as this is private non-NHS work.(Required)Consent I understand you may choose not to undertake this work at all, as it is not an NHS service. If, for whatever reason, you do not complete the work, I understand you will refund my fee.(Required)Consent I understand that I may only provide feedback about this service directly to your practice manager as the NHS complaints procedure does not apply to non-NHS work.(Required)SignatureDate DD slash MM slash YYYY Name First Last Contact telephone numberDate DD slash MM slash YYYY