Request an appointment with a nurse or healthcare assistant

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

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

Blood tests must be taken before 1.00pm.

You can also book blood tests directly using the NHS App or Patient Access.

Cervical screening:

I know that cervical screening is due now.

I am not sure when cervical screening is due. Please check records.

Please specify what other appointment:

Have you been told when to have the appointment, for example, “in the next two weeks” or “in one month’s time”?

Yes

No

When does the appointment need to be?

Tell us when you are available to have an appointment:

Tell us when you are available to have an appointment in the next three weeks:

Confirmation

I understand that the practice may need to send me a secure online message about my appointment. I will check my emails.

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