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? *

Routine – this may take up to 3-5 working days for a GP to contact you, depending on which practitioner you request to speak to

Same day – all requests will be triaged by a GP and dealt with on the day if it is deemed necessary

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?

When would you be available today for a phone call or video appointment (if needed)?

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.

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.

Maximum upload size: 67.11MB

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About the Patient’s Problem