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.

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 use the 111 online coronavirus service to find out what to do.

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 taken before 3pm and must have been requested by a clinician at the practice. If you require a blood test requested by another provider e.g. hospital you must bring your blood test form with you, without this we will not be able to proceed with the appointment.

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

Please specify the vaccination your require: *

If you require travel vaccinations, please complete our travel risk assessment instead.

To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before they can contact you to arrange your appointment.

Cervical screening:

If you would like to request an appointment with a Nurse Practitioner, please complete the Get help for any health problem form instead.

Have you been told when to have the appointment, for example, "in the next two weeks" or "in one month's time"? *
*