Non-Urgent Appointment Request Form

 
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All fields are mandatory

All questions marked with a * are mandatory

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Introduction

This form is to book a non-urgent routine appointment with a clinician within 2-6 weeks - Physician Associate, GP/Doctor, Clinical Pharmacist or Social Prescriber. 
Please complete this form as fully as you can. Our team will assess this information within 5 working days and will text you back. (We will not telephone you back. If you need to speak to a member of staff you should telephone the surgery).

 
  • Signs of a heart attack - pain like a very tight band, heavy weight or squeezing in the centre of your chest or any pain that moves into your jaw or neck
  • Signs of a stroke - face drooping on one side, can't hold both arms up, difficulty speaking, or weakness or numbness on one side of your body
  • Severe difficulty breathing - gasping, not being able to get words out, choking or lips turning blue
  • Heavy bleeding that won't stop - uncontrollable bleeding from any part of your body
  • Severe injuries - including deep cuts after a serious accident
  • Poisoning - you have swallowed something you should not have (medicines, batteries, household chemicals
  • Seizure (fit) - someone is shaking or jerking because of a fit, or is unconscious (can't be woken up)
  • Sudden, rapid swelling - of the eyes, lips, mouth, throat or tongue
 
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(Mandatory) Please confirm that
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Personal Details
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Is your Appointment for any of the following reasons
Are you requesting an appointment for: Hip/Knee/Wrist/Shoulder problem?: *
Have you tried the self referral to Physio?: *

Please continue to the next question

Are you requesting an appointment for: Anxiety/Depression/Low Mood/Worries/OCD?: *
Have you tried Talking Therapies?: *

Please continue to the next question

Are you pregnant / require maternal services - is this a medical issue?: *
Do you need an appointment to discuss Sexual Health?: *
Have you tried the Florey Clinic?: *

Please continue to the next question

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Appointment Questions
Do you need an appointment?: *
Is this chasing a response not yet received?: *

You need to telephone the surgery to chase (no multiple requests for the same query or checking progress of a request)

Please provide details of the condition or illness or concern you are requesting an appointment for (Each condition needs to be on a separate appointment request form)
Are you already undergoing treatment for this? If yes, what treatment?:
Is the treatment working?:
Has this been effective at all?:
What do you want from this request? :

Please be aware that you may be asked to telephone us back if it is not clear what your condition or request is regarding from the information provided. 

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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