Nurse/Health Care Assistant Appointment Request

Please do not use this service for any urgent medical queries as this service is only monitored during practice working hours.

You can use this form to request an appointment for services such as blood tests, blood pressure checks, applying dressings or for cytology (smear) tests.

Your Details

Patient's Full Name *

Patient's Date of Birth (dd/mm/yyyy) *

Email Address *

Mobile Phone Number

Landline Phone Number

Named GP (if known)

Appointment Details

Appointment With *

Appointment Date *

Appointment Time *

Appointment Type *

Reason for Appointment (Practice Staff other than doctors or nurses will read this)

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 17 January 2022
Page created: 14 October 2026

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Nurse/Health Care Assistant Appointment Request

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