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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Routine Appointment Request – Any

Routine Appointment Request – Any

Please note - if you do not hear back from our team within 5 working days, please contact us, as your form may not have been submitted successfully

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.

Are you seeking an appointment with a particular person? If so with whom?

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. Please note evening / weekend appointments have limited availability and you may wait for longer for an appointment if you only select this option.(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 Only)

Saturday Afternoons (Carterknowle Surgery Only)

In as few words as possible what is the subject of your enquiry. We will ask for more details later.(Required)

If applicable please send us a photo to help us process your form. Please can we ask you do not send us photos of genitalia.

Accepted file types: jpg, jpeg, png, gif, Max. file size: 128 MB.

Where is it e.g. arm, leg?(Required)

When did it start?(Required)

What is it like? For example if it is a pain, what does the pain feel like?(Required)

Does it go anywhere else?(Required)

Do you have any other symptoms with it?(Required)

How long does it last?(Required)

Does anything make it better or worse?(Required)

When does it occur?(Required)

How bad is it? (Consider a scale of 1-10 where 10 is the worst)(Required)

Have you had this before?(Required)

Have you tried any treatment for this?(Required)

Have you seen us about this before?(Required)

What is your occupation? (Some conditions are more common in some occupations).(Required)

Do you have any thoughts as to what the cause may be?(Required)

Is there anything you are worried about it with it? Including cause or consequence.(Required)

How would you like to us to help you? What were you hoping we can do?(Required)

Name

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

36592

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

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Personal Details

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Date of Birth*

Email Address*

Ethnicity*

CHANGE OF NAME

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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.

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CHANGE OF ADDRESS

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Please list all family members moving with you

UPDATE CONTACT NUMBERS

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Are you a carer?*

Yes, I am a carer for a friend/relative

Yes, I work as a carer in a residential/care home or community setting

No

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Comments

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33302

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