1 Carterknowle Road, Sheffield, S7 2DW

Telephone: 0114 229 1686

Sorry, we're currently closed. Please call NHS 111

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

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Routine Appointment Request – Skin Problem

Routine Appointment Request – Skin Problem

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 happy to travel to Porter Brook Medical Centre? Appointments are now offered out of hours (18:30pm-9pm)(Required)

Yes

No

(site address- 9 Sunderland Street Sheffield South Yorkshire, S11 8HN)

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.

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)

If possible please send us a photo. If it is a small single lesion including a coin or ruler on the photo will allow us to estimate its size. Whilst some skin lesions are difficult to get good photos of a picture can often be very helpful. If so please email it with the patient's name and date of birth to sheccg.carterknowle@nhs.net or click the "Choose File Button" below to attach photo's to this form(Required)

Yes

No

File

Max. file size: 128 MB.

In a few words, please explain the problem(Required)

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

When did it start?(Required)

Has it changed? If so, in what way and over how long?(Required)

Do you have get any symptoms from it?(Required)

Itch

Pain

Discharge/Leaking

Other

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 seen us about this before?(Required)

Have you tried any treatment for this?(Required)

When you are in the sun do you tan or burn?(Required)

Tan easily

Burn then tan

Burn easily

Have you lived or worked abroad? If so where and for how long?(Required)

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

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

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

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

Comments

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

30958

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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Email Address*

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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

Do you consent to being reminded by text for appointments?

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

52148

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