I want help with a medical request

About the Patient’s Problem

Please describe the problem: *

For example, I have back pain

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How long has this been going on for? Is it getting better or worse? *

For example, 2 weeks and getting worse

Have you tried anything to help? *

For example, physio or medication

Is there anything you are particularly worried about? *

How would you like us to help? *

For example, I would like to help manage my pain

Do you have any ideas about what is causing the problem? *

Please tell us the best times to contact you: *

We cannot guarantee a time and will only contact you during practice opening hours

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

Online message sent through your email

Telephone

Face to face appointment

Online message sent through your email

We might still need to phone you or arrange a face to face appointment. Please tell us if either of these would be a problem for you: *

Telephone

Are there any times today when you would not be free to 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 today when you would not be free for an appointment? *

Our doctors 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 either of these would be a problem for you: *

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?

How quickly do you think the problem needs to be dealt with? *

Within a few hours

Today

Tomorrow at the latest

It can wait a few days

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.

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About the Patient’s Problem

Online message sent through your email

Telephone

Face to face appointment