First Contact Practitioner physiotherapist appointment request

Section

About the Matter

Please specify: *

Please give a brief description of your main problem: *

How long have you had this problem? *

Less than 1 month

1-3 months

3-12 months

Over 12 months

Have you already seen a First Contact Practitioner for this problem? *

Yes

No

What type of appointment would you prefer? *

Online message sent through your email

Telephone

Video consultation

Face to face

Video consultations require you to have a smartphone, tablet, laptop or any computer with camera and microphone or headset. You will also require access to the internet, preferably over WiFi. If the practice decides on a video consultation you will be sent an email containing a link for the video consultation, so it’s best if you can receive your emails on that same device.

Online message sent through your email

We might still need to phone you or arrange a face to face appointment. Please tell us if either of these would be a problem for you:

Telephone

Are there any days/times when you would not be available to receive a phone call?

We might still need to send you a secure online message or arrange a face to face appointment. Please tell us if either of these would be a problem for you:

Face to face

Are there any days/times when you would not be available to have a face to face appointment?

We might still need to send you a secure online message or telephone you. Please tell us if either of these would be a problem for you:

You will receive a text or email message confirming your appointment details.

Terms & Conditions *

I confirm that this problem is not an emergency. I understand that the practice will not deal with this problem while the practice is closed.

If the problem worsens and may require immediate help, I will visit NHS 111 Online or call 111. In an emergency I will call 999.

Please upload any relevant evidence in relation to this request.

Maximum upload size: 67.11MB

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First Contact Practitioner physiotherapist appointment request

Section

About the Matter

Online message sent through your email

Telephone

Face to face