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Request an appointment with a nurse or healthcare assistant

Request an appointment with a Nurse or Healthcare Assistant (COVID-19)
Required fields are labelled
You must be aged 13 or over to complete this form yourself

COVID-19 Screening

Do you have either:

a high temperature – This means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – This means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normal
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you
Are you happy for us to make sure this number is updated in your medical record?
Have you, or the person you are requesting for, been advised to shield yourself because of your health? Required
The practice can send a text message to your phone with your appointment time. Required
Appointment required (tick all that apply):
Have you been told when to have the appointment, for example, “in the next two weeks” or “in one month’s time”? Required
Confirmation Required