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

Which GP (if known) requested this?

About your health concern

Please describe the symptoms you’re experiencing. *

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

How long have you had this problem or symptom, and is it a new, recurring, or ongoing issue? *

Please tell us when the problem started, whether you have experienced it before, and if it has recently changed or become worse

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.

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

What are your main concerns about this problem? *

What are you hoping we can help you with today?

For example: advice, a fit note (sick note), medication, a review, tests, a referral, a letter or form, or something else. This helps us understand what you are hoping to achieve and direct your request appropriately.

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)

Do you require a translator or interpreter?

Yes

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

Do you need help accessing the building?

Yes

For example, mobility or disability needs.

Please specify:

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.

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Get help for any health problem

Administrative information

About your health concern

Communication preferences

Final declarations