Request a GP Appointment

Note that we can only process forms for patients registered at The Hart Surgery. If you have been registered with us in the past, however and wish to re-register (eg students returning home), please mention that on your form.

If you require advice, a telephone call or a face-to-face appointment with a GP please fill in the form below

Full Name(Required)

Please use the full name that would be on your medical record

Date of Birth(Required)

DD slash MM slash YYYY

dd/mm/yyyy

How can we help? What are your symptoms?(Required)

Please give as much information about your symptoms as you can.

How long have you had the symptoms?(Required)

What have you tried / medications taken so far?(Required)

Photo upload

If you think it would help to upload a photo of your condition please click below.

Max. file size: 128 MB.

How quickly do you feel your problem needs to be dealt with?

GP to decideWithin 10 daysWithin 3 daysToday

Please note that the final decision on the urgency of an appointment will be made by the triaging GP

What type of appointment would you prefer?

Telephone

Face-to-Face

No preference

Please note that this would not be guaranteed and the final dcision regarding appointment type will be made by the triaging GP.

Are you happy for us to notify you of your appointment by text?

Yes, happy to receive a text

Email preferred

Telephone (or telephone message) preferred

It makes it easy for us if we can text and saves us time but we understand that this doesn't suit everyone.

Do you have a preference for a particular GP?

This cannot be guaranteed but we will take your preference, the nature of your condition, continuity and clinical urgency into consideration when allocating your appointment.

No Preference

Any female GP

Any male GP

My Registered GP (if available)

Are there any times/days you cannot make?

Contact Telephone number

This form was completed by

Me, the patient

Parent/Carer/Family Member

Hart Surgery staff

Care Home

Other

Email

If you would like confirmation that we have received your request please enter your email address (optional)

Comments

This field is for validation purposes and should be left unchanged.