Request a routine appointment

Confirmation

I confirm that this request is for a routine (not urgent) appointment.

Appointment required (tick all that apply):

Please state the blood test required (if known) and the reason for requesting it: *

Please state which vaccination is required: *

(For travel vaccinations, please use our Travel risk assessment form.)

Please give details:

Cervical smear: *

I confirm this is for a routine screening

Please state which type of contraception:

For example, tablet, injection, implant under the skin, coil.

Please give details of the appointment required: *

Have you been told when to have your appointment, for example, “in four weeks’ time”? *

Yes

No

When does the appointment need to be? *

Please tick below to indicate when you are available to attend an appointment:

Please provide details of any days/weeks over the next 6 weeks when you are not available to attend an appointment:

Are you happy for us to send your appointment date and time by text message? *

Yes

No

Please confirm your mobile telephone number (if different to the number given at the beginning of this form):

Confirmation *

I understand that the practice may respond to this request by email, and I will check my emails.

Tell us whether you accept cookies