Get help for any health problem

About the Patient’s Problem

What is the reason for your query today? *

Is this a new problem or is this something that you have been in to see us about before?

Is there anything else that you want to say about that problem? *

Have you tried anything to help with this problem already (self help, over the counter medication, pharmacy etc)? *

How long have you tried that for?

Has this changed at all since you last came to see us about it? (better/worse/same)

Is there anything specific that you were hoping to get from contacting us today? (GP review, treatment, a referral for further care, medication review, nurse appointment etc.) *

Is there a specific clinician you wanted to deal with your query?

Are there any times when you are not available if someone needs to contact you? *

Please note, if a phone call is needed, the clinician will try to call you twice. If you miss both of these calls, you’ll need to fill in another form.

What is your preferred method of contact? (phone call, text message, letter)

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.

Do you need an interpreter? *

Yes

No

Which language do you need? *

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.

I understand that this may take up to 3 working days for a GP to contact me, depending on which practitioner I request to speak to.

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

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About the Patient’s Problem