Request an appointment with a GP/clinician

About the Patient’s Problem

Please describe your current symptoms: *

When did your symptoms start? *

Does anything make your symptoms better? *

Does anything make your symptoms worse? *

Are your symptoms associated with any other symptoms? *

What treatments have you already tried and have they helped at all? *

Have you seen anyone previously about this? *

Yes

No

Who have you seen? *

Do you have any ideas what might be causing your symptoms? *

Do you have any concerns about your symptoms? *

What are your expectations from this encounter? *

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

Online message sent through your email

Telephone

Face to face appointment

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?

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.

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Request an appointment with a GP/clinician

About the Patient’s Problem