Get help for any health problem

Use this form to get help from your practice. We aim to respond within 1 day.

Please note that during busier periods this may take longer.

By completely this form you have confirmed you do not have a life threatening emergency. If you have a life threatening emergency please dial 999.

Any clinically urgent requests should be telephoned through to the surgery on 01502 712662.

Please be aware that this form is for both GP and Nurse Practitioner appointments.

Replies from the surgery may appear in your Junk inbox.

Get help for any health problem (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 use the 111 online coronavirus service to find out what to do.

About the Patient's Problem

If you're not sure, it's helpful to tell us whether it's been days, weeks, months or years.
Have you sought advice from a community pharmacist regarding your symptoms? *


There are occasions when patients need to be examined by a clinician which may involve intimate examinations. We are committed to putting patients at ease wherever possible. If you wish for a chaperone to be present during an examination, please specify below.

Does the patient require a chaperone present at the appointment? *

Are you hearing impaired?

BSL Interpreter

Does the patient require a BSL interpreter present at the appointment?

Appointment Type

Please note that after a form is received it will be reviewed by a trained Care Navigator.

How quickly do you think the problem needs to be dealt with? *

Anything assessed as priority will be booked into the next available slot (1-2 working days)

Routine health problems (this includes Reviews and follow up appointments) will be booked in within 1-2 weeks.

Video Consultation

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over wifi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it's best if you can receive your emails on that same device.

How would you like us to deal with the problem? *

Online message sent through your email


Face to face appointment

Home Visit

Home visits are only for patients who cannot come to the practice, not for transport issues. A clinician will usually phone you to discuss your need for a visit.

Please provide a blood pressure reading, if known.

Please fill in the home readings below if you know any of the following readings.

Will someone be with the patient? *
Do they have a disability?
Please view our full staff list.
Do you have a smartphone? *
The practice can send a text message to your phone with your appointment time. *
Terms & Conditions *
If you think it would be helpful, please upload photo(s) of your condition.
Drop a file here or click to upload Choose File
Maximum upload size: 67.11MB