Mitigating Circumstances Application

We can best provide support for your mitigating circumstances application, if you have consulted us, about your illness or medical problem or we have supporting hospital correspondence about it.

You should ensure the information you provide to us is accurate. Please be clear if there is any information which you do or do not wish to be included. Requests for subsequent amendments maybe charged for.

We will process your application as quickly as possible.

Payment Required

Now Accepting PayPal

Payment of £25 is required for this form. Payment may be made via PayPal. You will be directed to our PayPal Checkout page upon submission and the request will not be sent to the Practice until payment is processed. There is no requirement to have a PayPal account using this method and you can check out as a guest using credit card or debit card.

Mitigating Circumstances Application Form
Please use the same email address when you check out via PayPal.
Please use format day/month/year e.g. 12/05/1979
I consent to Gower Street Practice providing information about my health to the institution I attend
We require your consent
Do you wish to have a copy of the report?

Privacy Policy

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.