Get Help from a Doctor or Practitioner

If you are looking for advice for a child with a fever, please complete this form during our normal opening hours. Outside of our normal hours, please contact 111.

Confirmation

I confirm I have added the most up to date phone number

If you are using a UK mobile number, please use the format 07xxxxxxxxx

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/concern? (Optional)

What have you tried already (over the counter medication, self referrals etc)? (Optional)

How would you like us to help? (Optional)

If this is an ongoing problem, is there a member of staff who is currently dealing with this?

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

Online message sent through your email

Telephone

Face to face appointment

Please be aware, the preference above cannot always be accommodated. Reception may contact you any time from 08:00 to book this appointment with you.

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:

Are there any times this week when you are not available to be contacted?

Are you housebound?

Yes

No

Would you require a home visit?

Yes

No

Smoking Status:

Smoker

Ex Smoker

Never Smoked

Smoker

How many do you smoke a day?

Would you like help to give up smoking?

Yes

No

Ex Smoker

How many did you smoke a day?

When did you give up smoking?

Do you vape?

Yes

Ex Vaper

No

How often do you vape?

What nicotine strength and intensity do you vape?

For applicable devices

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.

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

Within a few hours

Today

Tomorrow at the latest

Does the patient require a translator?

Yes

No

Which language is required?

Does the patient require a BSL interpreter present at the appointment?

Yes

No

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.

Please provide images of the affected area, this will allow us to effectively triage your form. A Clinician will determine if a face-to-face appointment is required.

Drop a file here or click to upload Choose File

Maximum upload size: 20.97MB

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If you are looking for advice for a child with a fever, please complete this form during our normal opening hours. Outside of our normal hours, please contact 111.

About the Patient's Problem

Online message sent through your email

Smoker

Ex Smoker

New Patients