Consultation Request

Please use this form to submit a consultation request for Doctors, Nurses or Reception queries. These will be triaged by the surgery by 10am each morning so please bear in mind that if you submit it after this time, it may not be looked at by the surgery until the following working day.

If you are suffering with chest pain that you are concerned could be your heart, severe shortness of breath, have symptoms of stroke or believe that you are seriously unwell, please call 999 and do not use this form to request help.

We will reply by phone or text message. Please make sure that you provide us with your own phone number so we can communicate with you.

Not registered with Springfield Surgery, Sparkhill, Birmingham? Please contact your own GP surgery

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

May we contact you by text? *

Yes

Phone number for us to call you *

Mobile phone number for us to call or text you *

Your request

Who do you want to speak to? *

Doctor

Nurse

If you have had this problem before, who do you normally speak to about it?

What symptoms do you have? *

How long have you had them? *

Can you tell us anything you have done already to try to help these symptoms? Have you had pharmacy advice? *

How do you think we can best help you with these symptoms? Do you have any particular questions that you would like answering? *

Is there anything we need to bear in mind when arranging an appointment for you?

We can’t always accommodate all your needs but we will try to make life easier for you if we are able

Note: Employees unable to work because of coronavirus can access an online digital isolation note from 111.nhs.uk.

If you only need a sick note please use the sicknote request form.

Do you need medication? Please use our repeat prescription request service.

I understand that if I submit this request after 10am, it may not be viewed by Springfield Surgery until the next working day

I understand that if Springfield Surgery consider my request to be not urgent it may take up to 2working days to receive a response

Privacy Policy

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 my details secure?

The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible.

We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. When you submit your information, it is safely transmitted over the web in an encrypted form.

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

If you are human, leave this field blank.