Get Help for any Health Problem

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 (More information may still be required by text / telephone appointment)

Video Consultation

Online message sent through your email

*

I will check my emails including spam/junk 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

The practice offers some appointments with our local GP Service (GPHP). GPHP is co-owned by all local practices. The doctors and staff work within the local area but may not work for the practice. They will be able to view your medical records and will liaise with the practice if necessary. Do you consent to this service? *

Yes

No

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 try to be available to take a telephone call from the Practice if we need to contact you. We cannot give a precise time the Practice may call but it will show on your telephone as a withheld number, due to confidentiality a message may not be left. The Practice will try to call you twice before closing the request, following this you will have to submit another request.

*

Please tick to say that you have read and understood this message.