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Request a Patient Private Letter?

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Patient Private Letter Request

Required fields are marked with an asterisk (*).

Date

I would like to request a Private letter (TWIMC)…

Please provide your details below

Patient First Name*

Patient Surname*

Patient Date of Birth*

House Name/No.*

Town*

Patient Email address*

NHS No.*

Street*

Postcode*

Patient Telephone Number*

*Please note – You will receive an invoice via email or Text which requires paying via debit or credit card. This letter request will not be processed until payment has been received. The letter will take 28 working days from the payment date to be produced

Please tick to acknowledge you understand the above process

Reason for Letter Request*

Please give us details of your request that need to be included within the letter:*

Teldoc will require you to upload a copy of photo ID to allow us to proceed with your request

Evidence upload here*

* Please make sure all Mandatory fields have been completed

*Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. 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

Are you human?*

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Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

Other forms available

Register as Patient

Please visit our Patient Registration page and fill in the health questionnaire to register as a patient at Teldoc.

Change of Address

Please visit our Change of Name Form to update your details

Provide Feedback

Please visit our Feedback Form to provide feedback, make a suggestion or complaint.

More forms

Please visit the How Do I Portal for more forms

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Visit the How Do I portal for information on how to make an appointment, register at the practice and change your details