Get help for any health problem

Are you completing this form on behalf of:

Yourself

Someone else (e.g. a child or dependent)

About you

Your First Name(s): *

First Name(s) as appears on your passport.

Your Last Name: *

Last Name(s) as appears on your passport.

Your Date of Birth: *

Your date of birth is required to verify your identity.

Sex: *

Male

Female

Other

As on your medical record.

Your Phone Number: *

The practice may use this number to contact you about your request.

Your Email: *

This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you.

Please continue completing the form below

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. *

Do you have any ideas about what is causing the problem? (Optional)

What are the concerns? (Optional)

How would you like us to help? (Optional)

How would you like us to deal with the problem? *

Online message sent through your email

Telephone

Face to face appointment

Online message sent through your email

We might still need to phone you or arrange a face to face appointment. Please tell us if either of these would be a problem for you:

Telephone

Are there any times today when you would not be free to receive a phone call?

We might still need to send you a secure online message or arrange a face to face appointment. Please tell us if either of these would be a problem for you:

Face to face appointment

Are there any times today when you would not be free for an appointment?

Our doctors will decide whether an appointment is the best way to help you. We might need to send you a secure online message or phone you. Please tell us if either of these would be a problem for you:

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.

Is there a member of staff who would be best to deal with this problem?

How quickly do you think the problem needs to be dealt with? *

Within a few hours

Today

Tomorrow at the latest

It can wait a few days

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 & 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.