Liversedge Medical Centre

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Request a private GP letter

Fill in the form below to request a private GP letter.

First name(Required)

Surname(Required)

Date of birth(Required)

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Your current address(Required)

Contact number(Required)

Email(Required)

Enter Email Confirm Email

Reason for private letter request(Required)

To whom it may concern

Fit for Travel / Filming etc

For School or University

Fitness to attend a Gym

For Local Authority

Housing

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Please provide more information about your request(Required)

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Consent(Required)

By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.

I agree to the privacy policy.

Date published: 24th May, 2024
Date last updated: 21st February, 2026

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