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Horizon Healthcare NHS GP Surgery in Derby

Get help for any health problem

If you are submitting this form for someone else and we do not already have consent to discuss the patient’s care with you, we will be unable to process this request and will ask that the patient contacts us directly.

Administrative information

Have you already contacted us about this problem? *

Yes, this is a follow-up

No, this is new

Do you require a translator or interpreter? *

Yes

No

Please specify language or if British Sign Language (BSL): *

Do you need help accessing the building? *

Yes

No

For example, mobility or disability needs.

Please specify: *

About your health concern

Please describe the issue you’re experiencing. *

Include when it started, how it’s changed, and any symptoms you’re worried about.

Roughly how long has this been a problem? *

For example, “2 days”, “3 weeks”, “about 6 months”

Do you have any idea what might be causing the issue? *

What are your main concerns about this problem? *

Have you tried anything to help or manage the problem yourself?

Examples include medication, rest, advice from a pharmacist, or home remedies. Please tell us what you’ve tried and whether it helped.

Is there a member of staff who would be best to deal with this problem?

Communication preferences

Do you agree to receive appointment, referral or signposting details by text message or via the NHS App? *

Yes – I understand messages may go to the NHS App first if installed and I will ensure notifications are enabled

No – I do not want to receive texts or messages (please note this may delay your response)

Final declarations

Terms & Conditions *

I confirm this is not a medical emergency.

I understand the surgery cannot deal with this request outside normal opening hours.

I agree to contact 111 or 999 in case of worsening symptoms or urgent medical need.

I understand that completing this form does not guarantee an appointment.

If you are human, leave this field blank.

Burton Road
Horizon Healthcare
City Site
3-5 Burton Road
Derby
DE1 1TH

Get directions

01332 737777

Humbleton Drive
Mackworth Surgery
Humbleton Drive Branch
31 Humbleton Drive
Mackworth
Derby
DE22 4AU

Get directions

01332 737777

Register with the surgery

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