Are You A Carer?

Do you look after a family member or friend who is unwell, disabled or frail?

Are You A Carer?
Do you look after a family member or friend who is unwell, disabled or frail?
If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer, which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments.
Carer details
DD slash MM slash YYYY
Details of Person Being Cared For
DD slash MM slash YYYY
Is the person you care for a patient at NHS GP?

Your Accessibility Needs

Your Accessibility Needs
We want to get better at communicating with our patients. We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.
Your Details
DD slash MM slash YYYY

Travel Questionnaire

Travel Questionnaire
Personal Details
MM slash DD slash YYYY
Trip Dates
DD slash MM slash YYYY
Itinerary
Trip Description - please tick all appropriate boxes:
Purpose of trip:
Type of trip:
Accomodation:
Travelling:
Location type:
Activity type:
Personal medical history
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Have you ever had any of the following vaccinations / tablets and if so, when?

The General Practice Assessment Questionnaire (GPAQ)

The General Practice Assessment Questionnaire (GPAQ)
3 b) What additional hours would you like the practice to be open? (please tick all that apply)

Signing Up For Patient Reference Group

Signing Up For Patient Reference Group
If you are happy for us to contact you periodically by email please fill out all the fields below and send the completed form to us.
Your details
DD slash MM slash YYYY
The information below will help to make sure that we receive feedback from a representative sample of the patients registered at this practice.
Your Gender
Your Age
The ethnic background with which you most closely identify is:
How would you describe how often you come to the practice?

Sick Note Request form

Requesting Fit Note (Med3)
The more information you put in this form, the more opportunity we have to help you with your Fit note request
Your details:
DD slash MM slash YYYY
The next part of this form, is you opportunity to clarify why you are asking for a fit note.
DD slash MM slash YYYY
DD slash MM slash YYYY
Please email any supporting documents to docman.e84066@nhs.net