Get help for any health problem – routine

Terms & Conditions Required

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.

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

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. Required

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

What are the concerns? Required

How would you like us to help? Required

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. Required

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 Required

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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Get help for any health problem – routine

About the Patient’s Problem

High Demand