Get Help for any Health Problem

About the Patient's Problem

Have you already visited a pharmacy / chemist about this problem? *

Yes

No

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed. *

Failure to provide details will delay your request being triaged

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 need to phone you or arrange a face to face appointment. Please tell us if there are times when either of these would not be possible:

Telephone

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

Our clinicians 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 there are times when either a phone call or face to face appointment would not be possible:

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

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

This practice is a training practice. As part of our ongoing training and education we might sometimes wish to record, video or telephone consultations for training purposes only. This will only be viewed by a senior GP in the practice and will be deleted immediately afterwards. If you are unhappy with this and do not want to be recorded, please indicate below:

I am unhappy with this and do not want to be recorded

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.

I confirm that I am in the UK at the time of making this request.

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About the Patient's Problem

Online message sent through your email

Telephone

Face to face appointment