Get help for any health problem

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.

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

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 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:

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.

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

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

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.

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.

Tell us whether you accept cookies

About the Patient’s Problem

Online message sent through your email

Telephone

Face to face appointment

Forms only available during working hours