Online Request Form

Online Request Form
Please DO NOT complete this form if you have any of the symptoms below. Please phone 999.
- Possible heart attack/stroke
- Severe chest pains
- Severe breathing difficulites
- Severe allergic reation or anaphylaxis
- Fitting
- Drowsiness, confusion or unconsciousness
- Severe burns or scalds
- Suffered trauma or a head injury
Please tick to confirm you do not have any of the symptoms listed above*

I DO NOT have any of the above symptoms
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.
Please tick to confirm*

I consent to the practice collecting storing and updating my data from this form
Please tick if completing this section on behalf of a patient under 16 years of age.

I can confirm that I am the parent/guardian responsible for the patient I am completing this form on behalf of.
Name of parent/guardian (if filling in form on behalf of patient under 16yrs of age.
Full Name*
Date Of Birth*

DayMonthYear
Address*

Street Address

City

Post Code
Phone Number*
Preferred Number
Phone Number
Alternative Number
Email
You will receive a confirmation email when submitting this form
The practice will contact you usually within TWO working days regarding your online form.
Please select which service you require today*

GP consultNursing consultAdmin queryPharmacy/Medication queryRequest for medicationRequest for fitnoteOther
Please complete the relevant section below.

GP Consult/Nursing Consult
Reason for contacting us
How many days have you had these symptoms?
Self care - (visited pharmacy, tried over the counter medication)
Expectation

Face to face appointmentTelephone ConsultationPrescriptionFitnoteOther
Availabilty (Please let us know when you are not available to be contacted)*
If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3 - 5MB) for the GP/Nurses attention. Pollokshaws Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be filed into your medical records. If you do not wish for this to happen please advise the surgery.

Browse Files

Cancelof

Requesting a fitnote
Reason for the fitnote
Date from

DayMonthYear
Date to

DayMonthYear
I would like to receive my fitnote via email

YESNO
Email Address (if you have selected "YES")

Request for medication
Please allow TWO working days for the processing of prescriptions. If you request is urgent please let us know in the box below, or contact the surgery direct.
Medication required.
If you would like your prescription to go to a local pharmacy to us, please leave the name in the box below.

Admin/Pharmacy/Medication/Other Query
Query information

Feedback (Positive or negative we welcome your feedback - This is optional)
Should be Empty:

Online Request Form

Privacy Policy