Non Urgent Doctor or Nurse Practitioner Appointments

Are you happy for us to make sure this number is updated in your medical record?

Yes

No

Have you, or the person you are requesting for, been advised to shield yourself because of your health? *

Yes

No

Have you, or the person you are requesting for, left your house since the end of March or since received advice to shield?

Yes

No

Please tell us what kind of trips you have made when you have left the house, for example medical appointments, shopping, etc.

Have you or the person you are requesting for, had anybody visit you in your home?

Yes

No

Please tell us who has visited you, for example a family member or carer:

Are other members of your household socially distancing from you?

Yes

No

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. We need you to provide us with this information so that we know how to help you. *

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? (Optional)

What are the concerns? (Optional)

How would you like us to help? (Optional)

If your problem is to do with joints and muscles, we may refer you to the First Contact Practitioner physiotherapy service. Please specify if you are happy for us to do so:

I consent to be referred to the First Contact Practitioner physiotherapy service

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

Online message sent through your email

Telephone

Face to face appointment

Please bear in mind that we may not be able to deal with your problem in your preferred manner.

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.

Please specify if you have seen anyone about this problem before:

Please view our full staff list.

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 – Please select both boxes before submitting *

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.

If you think it would be helpful, please upload photo(s) of your condition. If you have a rash, acne, or anything that needs to be viewed by the clinician, please upload images of the issue.

Maximum upload size: 67.11MB

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Non Urgent Doctor or Nurse Practitioner Appointments

Important: IMPORTANT

About the Patient’s Problem

Online message sent through your email

Telephone

Face to face appointment