Pre-bookable appointment request

Section

Is this your up to date telephone number? *

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. *

Do you have any ideas about what is causing the problem? (Optional)

What are the concerns? (Optional)

How would you like us to help? *

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

Telephone

Face to face appointment

We will reply in the first instance and wherever possible by email as this preference cannot always be accommodated.

Telephone

Do you have a preferred day?

Face to face appointment

Do you have a preferred day?

Do you require a translator?

Yes

No

Which language do you require?

Do you have a preferred clinician?

This is not guaranteed but we will always try book with them if possible.

Terms & Conditions *

I confirm that this problem is not an emergency. I understand that the surgery will not deal with this problem while it is closed and that it may take up to two working days for the surgery to contact me.

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 understand that I am booking a routine, pre-bookable appointment, which may involve a wait, typically around four weeks in advance. The surgery will do its best to minimise the wait time, but I acknowledge that some delay is normal for non-urgent appointments.

If you think it would be helpful, please upload photo(s) of your condition.

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Section

About the Patient’s Problem

Telephone

Face to face appointment