Request a Follow-Up Appointment

Request a Follow-Up Appointment

Please use this form to request a follow‑up appointment that has been recommended by a healthcare professional (GP, nurse, pharmacy, or A&E). Submission of this form will be reviewed by the team and a link to book an appointment will be sent to the email provided.

Please complete this section if you are completing the form on behalf of someone else.

About You (The Patient)

Name  Required
Date of Birth  Required
Address  Required
What is your sex assigned at birth?  Required

Follow Up Appointment

Who requested the follow-up appointment?  Required

Details of the Referring Service

Name of GP/ Nurse / Pharmacy / Hospital  Required
Date of Referral  Required
Urgency of Request  Required
Preferred Appointment Type  Required
Please include any other information that may be helpful (e.g. hospital letters, discharge advice, medication changes):
Privacy Protection  Required

Additional Information

Carers

Chaperoning

GDPR, Data Processing and Subject Access Request (SAR)

Infection Control

Long Term Conditions

Summary Care Records

Zero Tolerance Policy

Non-NHS Services

Patient Participation Group

Responsibilities

Talking Saves Lives

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