Request an appointment with a Nurse or Healthcare Assistant

Tell us when you want your appointment and we will reply to you with a time. Once we receive this form we will process it within 2 working days.

Please be aware that once this form has been submitted, it will be held within your health record.

Request an appointment with a Nurse or Healthcare Assistant (COVID-19)

COVID-19 Screening

Do you have either:

a high temperature - This means you feel hot to touch on your chest or back (you do not need to measure your temperature) *
a new, continuous cough - This means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) *
loss or change to your sense of smell or taste - this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal *
Have you been told by 111 to contact the practice? *
Do you live with someone who has had a high temperature or a new, continuous cough? If their symptoms started more than 14 days ago, click No. *
Please continue to fill out this form
Your symptoms suggest you might have Coronavirus (COVID-19). You should contact the 119 service to arrange a test or use the 111 online coronavirus service for medical advice about your symptoms.

Section

The practice can send a text message to your phone with your appointment time. *
Appointment required (tick all that apply):

Blood tests must be no later than 15:30

If you would like to request an appointment with a Nurse Practitioner or Doctor, please complete the Get Help For Any Health Problem form.

Cervical screening: *
Have you received your cervical screening invitation letter? *
Have you been told when to have the appointment, for example, "in the next two weeks" or "in one month's time"? *
Terms & Conditions (please select all the checkboxes below) *