Healthcare professional contact request

If the patient is to be seen within 24 hours

Do not use this form and call the duty team at the Hollies Medical Practice directly by phone on 01827 217799.

Patient Details

First Name: *

Surname: *

Date of Birth: *

Please use date format: DD/MM/YYYY

NHS Number: *

Mobile Number: *

Home Number: *

Address: *

Usual GP: *

Contact Details of Professional Making Contact

First Name: *

Surname: *

Job Role: *

Name of Organisation: *

Office Number: *

Mobile Number: *

Email Address: *

All responses will be sent to this email address

Do you have consent from the patient to call on their behalf? *

Yes

No

Availability for contact to be made: *

Please provide days and times

Contact Details of 2nd Professional with Responsibility

If first contact is unavailable

First Name:

Surname:

Job Role:

Name of Organisation:

Office Number:

Mobile Number:

Email Address:

Do you have consent from the patient to call on their behalf?

Yes

No

Availability for contact to be made:

Please provide days and times

Information Required

Do they need a Doctor’s input, or can the query be resolved from a Practice Pharmacist? (eg. for drug queries) *

Doctor

Practice Pharmacist / Medication Query

Don’t know

Urgency of Request

How soon does the patient need to be seen? *

Soon – Within 1 week

Routine – 2 to 4 weeks

Please give exact details of the problem: *

What is the patient’s and referrer’s expectation? *

What has been tried already? *

What usual medications does the patient take?

What allergies does the patient have?

Other Agencies Involved

District Nurses – contact number: 0300 124 0347

Social Services – contact number: 0300 111 8010

Community Pharmacy – NHS: How your pharmacy can help

Community Mental Health Team – contact number: 0300 555 5001

If you have not already, please consider contacting them first if appropriate.

Has the referrer tried other agencies that may be able to help?

District Nurses

Social Services

Community Pharmacy

Community Mental Health Team

Select all that apply

Please list and note their involvement with contact details of who has been involved: *

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Important: For professional use only