GP intervention request

Important: For care home use only

All nursing and care home staff are able to submit a GP intervention request form on behalf of their residents, who are registered patients of Orchard Surgery.

Requests must be submitted before 11:00.

GP Intervention Request

Please ensure all requests are received before 10:00. Coordinate all interventions with one point of contact for GP surgery to call.

Care Home: *

Room Number: *

Section

Coordinator Name:

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: *

How long has this been a problem? *

Observations:

Readings

Please provide the readings below.

Systolic “Higher”

Diastolic “Lower”

Pulse

Sats

Temperature

Blood Glucose

Respiratory Rate

Other Details

Sputum Colour:

Is the patient coughing or chesty?

Yes

Please specify if the condition is acute or chronic:

Acute

Chronic

Further Information:

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

Telephone

Appointment

Visit

Completed By

Your Name: *

Your Position: *

Date:

Time:

Please upload any relevant paperwork/documents relevant to this request:

Maximum upload size: 67.11MB

Terms and conditions *

We accept that it is our duty of care to check replies from the surgery which will be sent via email and action where appropriate