. Telephone Consultation Request
 
290 Knowsley Road, Bootle, Merseyside, L20 5DQ
Tel: 0151 922 3841
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Telephone Consultation Request
Your Details
Name: *
Date of Birth: *
Postcode: *
Day Time Telephone: *
Email: *
Confirm Email: *
Your Doctor:
Telephone Consultation Details
Consultation With:
On:
When:
Reason for Telephone Consultation
Practice staff other than the doctor or nurse will read this:
   
 
About This Form
By sending this form you are not booking an appointment or telephone consultation. You are requesting that a routine appointment or telephone call be booked for you. This is why you cannot specify an exact time and date. Should you feel that you have an urgent medical problem, please contact the surgery directly by telephone, rather than using this form.
When an appointment or call has been booked for you, an email will be sent with the details. You must ensure that you do not have a spam-blocker installed or any other kind of software that will reject this automatic email.
If, for some reason, you are unable to keep the appointment or accept the call please phone the surgery and cancel as soon as possible.
 
Please Note
By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should call the surgery to request an appointment.
 
Personal Information
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
 
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