Non-Urgent Advice/Appointment Request

Non-Urgent Advice/Appointment Request

THIS FORM IS TO BE COMPLETED FOR NON-URGENT(ROUTINE) TRIAGE.

IF YOU HAVE AN URGENT REQUEST, PLEASE CALL RECEPTION ON 03453371140. IF YOU HAVE A MEDICAL EMERGENCY, PLEASE CALL 999

THIS FORM IS ONLY TO BE COMPLETED IF SPECIFICALLY REQUESTED BY A MEMBER OF STAFF.

PLEASE ALLOW 2 WORKING DAYS FOR A RESPONSE.

Your Details

Full Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number

Email Address (optional)
Request Details

Please state the current symptoms you are experiencing, or the advice you require.

When did the problem/symptoms start?

Are you taking/have you tried any medications for this problem?

Have you sought help for this problem previously?

Have you been referred for investigation of this problem?

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

I consent to the practice collecting and storing my data from this form.

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Page last reviewed: 01 July 2026