1 Carterknowle Road, Sheffield, S7 2DW

Telephone: 0114 229 1686

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137 Dore Road, Dore, Sheffield, S17 3NF | Telephone: 0114 229 1686

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Brief routine appointment request

Brief routine appointment request

Brief Routine online request form – Blood tests, smear test, B12, child immunisations, ear syringing

Please note this form is for routine simple requests, such as requesting an appointment for a smear test or a blood test. You cannot use this form to request your own bloods, please only use this form if the blood test you require has been requested by a clinician or is a repeat test that is due. Please do not use this form if you are unwell, as this form will not triage your symptoms appropriately.

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone Number(Required)

If you are not the patient above but are completing it on their behalf please give us your name and phone number should we need to speak to you?

Consent(Required)

I confirm I have read the below statement and my enquiry is not urgent(Required)

I confirm I am not reporting an acute infective illness that may require more prompt medical treatment such as urine infections, chest infections, tonsilitis, scarlet fever or illnesses where clinical response is needed urgently (Forms can take up to two working days to be seen and runs the risk that the condition is not treated in a timely manner. If your enquiry is relating to an infection or acute illness, this should be phoned through that day or advice sought from the walk-in-centre or 111 / GP out of hours services if we are closed).

Consent(Required)

I consent to the practice collecting and storing my data from this form.(Required)

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

There is also availability on a Saturday day time, or evening (Mon-Fri 18:30-21:30pm), would you be happy if we arranged an appointment during these times?(Required)

Yes

No

Our team will arrange an appointment on your behalf and text you to let you know when it is. Please advise your availability below. Many people want appointments at similar times so the more options you give us the sooner the date we can book the appointment for.(Required)

Monday Mornings

Monday Afternoons

Tuesday Mornings

Tuesday Afternoons

Wednesday Mornings

Wednesday Afternoons

Thursday Mornings

Thursday Afternoons

Friday Mornings

Friday Afternoons

Evening Appointment Monday – Friday 18:30 – 21:30 (Carterknowle Surgery Only)

Saturday Mornings (Carterknowle Surgery)

Saturday Afternoons (Carterknowle Surgery)

What appointment is it you require?(Required)

Smear Test (cervical screening)

MMR Vaccination

B12 Injection (I bring my own injection)

B12 Injection (I require an injection from the surgery)

Childhood immunisations

Blood test (Please note, we cannot book bloods that you have requested yourself, we can only book you in if a clinician has requested them beforehand).

Ear Syringing (I have had this done before)

Ear Syringing (I have have not had this done before)

If it is a blood test appointment that you require, please provide details of which clinician requested the bloods below.

You can also advise our team if the test is a fasting blood test or any other relevant details.

Phone

This field is for validation purposes and should be left unchanged.

23007

Zero Tolerance

Veteran Friendly

Carterknowle Surgery
Opening Times

Monday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Tuesday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Wednesday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Thursday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Friday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Saturday
CLOSED
Sunday
CLOSED

Dore Surgery
Opening Times

Monday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Tuesday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Wednesday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Thursday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Friday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

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NHS 111

Patient UK

Cervical Smears

NHS A-Z Conditions

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Staff Login | Privacy Policy | Accessibility

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Personal Details

Name*

First Last

Date of Birth*

Email Address*

Ethnicity*

CHANGE OF NAME

Previous surname

Please note we cannot change your name without a change of name document. This can be marriage certificate, deed poll etc. Our team will be in touch to ask you for this if you have requested to change your name.

How do you wish to be known?

Dr

Mrs

Mr

Miss

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Other

CHANGE OF ADDRESS

Previous Address, including postcode

New Address, including postcode

Please list all family members moving with you

UPDATE CONTACT NUMBERS

Do you consent to being reminded by text for appointments?

Yes

No

Number Type

New Phone Number

Email

This field is for validation purposes and should be left unchanged.

21757

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Essential: Remember your cookie permission setting
Essential: Allow session cookies
Essential: Gather information you input into a contact forms, newsletter and other forms across all pages
Essential: Keep track of what you input in a shopping cart
Essential: Authenticate that you are logged into your user account
Essential: Remember language version you selected
Functionality: Remember social media settings
Functionality: Remember selected region and country
Analytics: Keep track of your visited pages and interaction taken
Analytics: Keep track about your location and region based on your IP number
Analytics: Keep track of the time spent on each page
Analytics: Increase the data quality of the statistics functions
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