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Foundation Surgery NHS GP surgery

Request a routine appointment

Routine appointment request

Form summary

Do you know the type of routine appointment you need? *

For example, a follow-up, blood test, health review or cervical screening (smear test)

Yes

I’m not sure

About the appointment

What type of appointment do you need? *

Why do you need this appointment? *

Tell us about the problem and if someone asked you to make this request

About the problem

Tell us about the problem and your symptoms *

It may help to describe the problem as if you were speaking to someone

How long has this been a problem? *

It is helpful to tell us if it has been days, weeks, months or years

Do you have an idea about what is causing the problem? *

This might be something that happened or you found around the time your symptoms began

Can you think of anything that is worrying you about the problem? *

Is there a member of staff that you would prefer to deal with the problem?

You may need to wait longer for your preference as it depends on their availability

Upload a photograph or document

Maximum upload size: 5.24MB

Have you been told when to have the appointment? *

Yes

When does the appointment need to be? *

When are you available to have the appointment? *

When are you available to have the appointment in the next 3 weeks? *

How would you prefer to be contacted? *

Phone

Text message

Video call

Are there any times when you cannot be contacted? *

Terms and conditions *

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

If you are human, leave this field blank.

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