GP ROUTINE Appointment

24th October 202524th October 2025

GP ROUTINE Appointment – Triage Request Form

Practice Name: [Insert Practice Name]
Form Type: ROUTINE GP Appointment Request
Availability: 8:00am – 6:30pm (Core Hours Only)

Important Information for Patients

This form is for ROUTINE (non-urgent) issues only.

Your request may not be reviewed for up to 72 hours (3 working days).

If you feel your problem cannot wait, please use our Medical Request Form (available 8:00am–12:00pm, Monday to Friday) or call the practice.

If your symptoms worsen or you feel acutely unwell, contact NHS 111 or in an emergency, call 999 or present at the practice/Emergency Department.

1. Patient Details

Field	Information
Full Name
Date of Birth
Address
Contact Number
Email Address
Preferred Contact Method	☐ Phone ☐ Text ☐ Email
Consent to receive messages via Accurx or SMS?	☐ Yes ☐ No
Are you completing this form for yourself?	☐ Yes ☐ No – on behalf of someone else (relationship)

2. Reason for Request

Please describe the issue you would like help with today:

How long have you had this issue?
☐ Less than 1 week ☐ 1–4 weeks ☐ More than 1 month

Has this issue been discussed with a GP or nurse before?
☐ Yes ☐ No

3. Preferred Clinician / Appointment Type

Who would you prefer to see?
☐ Any GP ☐ Named GP: ___________________ ☐ Pharmacist ☐ Practice Nurse ☐ Healthcare Assistant

Preferred appointment type:
☐ Telephone ☐ Face-to-face ☐ Either

Any days/times you cannot attend?

4. Additional Information

Are you currently receiving care from another service (e.g. hospital clinic, mental health team)?
☐ Yes ☐ No – If yes, details: _________________________________

Do you consider yourself to have additional needs or vulnerabilities (e.g. learning disability, carer, safeguarding concerns)?
☐ Yes ☐ No – If yes, details: _________________________________

5. Declaration

I confirm the information provided is accurate.

I understand this form is for ROUTINE (non-urgent) issues and my request may not be reviewed for up to 72 hours (3 working days).

I understand that if my issue is more urgent, I can submit a Medical Request Form (8:00am–12:00pm, Mon–Fri) or call the practice.

Signature (if paper): ____________________

Date: ____________________