Get help for a medical problem

If you are filling in this form on behalf of the patient, we are unable to discuss confidential patient information about people aged 18 or over with third parties without prior written agreement.

If there is no written agreement in place, please ask the patient themselves to complete this form.

About the Matter

Please provide as much information about the problem as you can, to enable us to help you as best we can. For instance, if you have pain, where is it, what does it feel like, does it travel anywhere else? Have you had any other symptoms that you think might be relevant? Have you tried anything to help with your problem so far?

Please tell us about the matter. If the practice is already aware of this problem, please tell us what has changed. *

Do you have any ideas about what is causing this? (Optional)

What are your concerns? (Optional)

The practice can send a text message to your phone with your appointment time. *

I agree to the practice sending me text messages including appointment times

I do not agree to the practice sending me a text message with my appointment time

Terms & Conditions *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency I will call 999.

If you think it would be helpful, please upload photo(s) of your condition.

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About the Matter