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Get help for any health problem – Routine – Form

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Terms & Conditions *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.
If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency I will call 999.

About the patient

Name *

First

Last

Date of birth *

Sex *

Female
Male

Postcode *

Email address *

Confirm Email

Phone number *

Are you completing this form on behalf of someone else? *

Patient's name *

First

Last

Patient's date of birth *

Your relationship to the patient *

About the Patient's Problem

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed. *

How long has this been a problem? *

If you’re not sure, it’s helpful to tell us whether it’s been days, weeks, months or years.

Do you have any ideas about what is causing the problem? *

What are the concerns? *

How would you like us to help? *

Our doctors will decide whether an appointment is the best way to help you. We might need to send you a secure online message via email, phone you or arrange a video appointment.

Video Consultation

I am willing to accept a video consultation

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over WiFi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it’s best if you can receive your emails on that same device.

The practice can send a text message to your phone with your appointment time. *

I agree to the practice sending me text messages including appointment times
I do not agree to the practice sending me a text message with my appointment time

Terms and Conditions *

I understand that I will receive a response via email, text or phone. I acknowledge that I will need to check my emails including junk mail

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