Get Help for any Health Problem

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) *

Yes

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) *

Yes

Have you been told by 111 to contact the practice? *

Yes

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. *

Yes

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.

Preferred phone number you would like to be contacted on:

About the Patient's Problem

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed. *

Do you have any ideas about what is causing the problem? (Optional)

What are the concerns? (Optional)

How would you like us to help? (Optional)

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

Online message sent through your email

Telephone

Online message sent through your email

We might need to phone you or arrange a face to face appointment. Please tell us if there are times when either of these would not be possible:

Telephone

Are there any times when you cannot receive a phone call?

We might still need to send you a secure online message or arrange a face to face appointment. Please tell us if either of these would be a problem for you:

Face to face appointment

Are there any times when you would not be free for an appointment?

Our clinicians will decide whether an appointment is the best way to help you. We might need to send you a secure online message or phone you. Please tell us if there are times when either a phone call or face to face appointment would not be possible:

Is there a member of staff who would be best to deal with this problem?

The practice can send a text message to your phone with your appointment time. *

I agree to the practice sending me text messages including appointment times

I do not agree to the practice sending me a text message with my appointment time

Terms & Conditions *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency I will call 999.

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COVID-19 Screening

Do you have either:

About the Patient's Problem

Online message sent through your email

Telephone

Face to face appointment

Seasonal Flu