CHARGES FOR NON-NHS MEDICAL SERVICES



CHARGE SHEET FOR NON-NHS MEDICAL SERVICES

Patient Name: Dr: Date: / /

Patient Number:

£ VAT 20% £

|Private Sickness Certificate |15.00 |0.00 |15.00 |

|To Whom It may concern (VAT may be added depending on type of request) |15.00 |0.00 |15.00 |

| |15.00 |3.00 |18.00 |

|Incapacity – Letter for Employer/College etc |50.00 |10.00 |60.00 |

|Private Prescription for travel medication (anti-malarial drugs, etc) |10.00 |0.00 |10.00 |

| | | | |

|Private Prescriptions |10.00 |0.00 |10.00 |

|Sickness / Accident/Income& credit protection Insurance Claim Forms (Incl BUPA/PPP claims) |25.00 | 0.00 |25.00 |

|Holiday Cancellation Certificate / Fitness to Travel Certificate |30.00 |6.00 |36.00 |

|Medication letter (a review document can be issued for free!) |25.00 |0.00 |25.00 |

|School/University Sickness/Exam Letter |15.00 |0.00 |15.00 |

|Endorsement of Driving Licence Application | | | |

|School Fees Insurance Claim Form |25.00 |5.00 |30.00 |

|Extract from records – Fitness statement (incl. fitness to participate in sports / fitness to drive) | | | |

|Road Traffic Accident Consultation Fee |21.30 |0.00 |21.30 |

|Firearm / Shotgun licence Application |35.00 |7.00 |42.00 |

|HGV / PSV Medical Examination & Report (x 3 appointments) |60.00 |12.00 |72.00 |

|Taxi Medical Examination & report (x 3 appointments) | 60.00 |12.00 |72.00 |

|Pre - Employment Medical & report (x 4 appointments)(includes fitness to join pension scheme) |100.00 | 20.00 |120.00 |

|Post – Employment Medical & report |100.00 |20.00 |120.00 |

|Employment extract from records ( no examination > 30 mins) |50.00 |10.00 |60.00 |

|Private Medical Examination & report (x 4 appointments) e.g Boxing Medical |100.00 |20.00 |120.00 |

| | | | |

|Private Medical Examination & report (x2 appointments) e.g Motor Sports Medical |50.00 |10.00 |60.00 |

|Private Medical report (no examination - > 30 mins) (includes Criminal Injuries) |100.0050.00 |20.00 |120.00 |

|Private Medical report (no examination - < 30 mins) (includes Criminal Injuries) | |10.00 |60.00 |

|Health Declaration – Childminder |25.00 |5.00 |30.00 |

|Motor Sports Medical (x 2 appointments) |50.00 |10.00 |60.00 |

|Computerised Medical Records |10.00 |0.00 |0.00 |

|Manual Records or Combination of both |50.00 |0.00 |0.00 |

|Certificate Provider for Lasting Power of Attorney |75.00 |15.00 |90.00 |

|Certificate Provider for Lasting Power of Attorney requiring a Home Visit |100.00 |20.00 |120.00 |

|Home visit for Assessment of Capacity (court of protection) |60.00 |12.00 |72.00 |

|Additional Fee – Doctor to complete | | | |

PLEASE NOTE THE ABOVE CHARGES ARE MINIMUM FEES AND WE RESERVE THE RIGHT TO CHARGE AN ADDITIONAL FEE DEPENDING ON THE AMOUNT OF WORK INVOLVED FOR EACH REQUEST

We regret that we are unable to waive fees where medicals are required to undertake charity events. We have numerous requests of this nature and whilst we would like to be able to waive fees the partners would prefer to choose which charities they support.

DOCTOR – PLEASE CIRCLE APPROPRIATE CHARGE

|PAYMENT RECEIVED & COPY OF RECEIPT CHECKED |RECEIPT NO: |CASH/CHEQUE |

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Partners

DR PETER SMITH

DR MARY NICHOLS

Dr BETH LYNCH

DR MATTHEW BEST

DR LISA KELLY

THE SURGERY

WESTELLA ROAD

YELVERTON

DEVON

PL20 6AS

Tel: 01822 852202

Fax: 01822 852260

VAT Reg No. 879108193

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