Request an Appointment Request an Appointment These forms are not monitored in real-time. If you need to be seen as soon as possible, consider calling the surgery or visiting an Urgent Treatment Centre. In an emergency, go to A+E or call 999.Your DetailsWhat is your name? First Last What is your date of birth? Day Month Year What is your postcode? What is your contact number?About your AppointmentI would like an appointment with… the Doctor (GP) the Nurse a Pharmacist Please briefly describe why you would like to see the Doctor. OptionalThis helps us to provide you with the best care within the most suitable timeframe, potentially utilising a different service or clinician.Please select the option that best describes your problem. This is a new problem. This is an existing problem that is getting worse. This is an existing problem that has stayed the same. Other How long have you had this problem? Less than 24 hours 1 – 3 days 3 – 7 days 1 – 2 weeks 2 – 4 weeks More than 1 month I need an appointment with the Nurse for… Annual Review Asthma Review Baby Immunisations Blood Pressure Check Blood Tests COPD Review ECG Injections / Vaccinations New Patient Check Smear (Cervical Screening) I need an appointment with a Pharmacist for… Blood Pressure Check Hypertension Review Medication Review Have you been told when to have the appointment?e.g. “after two weeks”, “in a month’s time”, “on or after this date” Yes No Enter the earliest date that you have been told to have your appointment. DD slash MM slash YYYY SMS Text MessagingWe may send you an SMS text message to book your appointment, or with confirmation of your appointment time. We will send the message to the mobile number stored on your records. Please indicate below whether you wish to receive these messages. I consent to receiving SMS text messages regarding my appointment. Optional Comments OptionalThis field is for validation purposes and should be left unchanged.