Use this service to request a referral from a doctor.
You can use this service if you:
- are registered at the surgery
Before you start
Call 999 or go to A&E now for any of these:
Signs of a heart attack
chest pain, pressure, heaviness, tightness or squeezing across the chest
Signs of a stroke
face dropping on one side, can’t hold both arms up, difficulty speaking
Sudden confusion (delirium)
cannot be sure of own name or age
Suicide attempt
by taking something or self-harming
Severe difficulty breathing
not being able to get words out, choking or gasping
Heavy bleeding
spraying, pouring or enough to make a puddle
Severe injuries
after a serious accident
Seizure (fit)
shaking or jerking because of a fit, or unconscious (can’t be woken up)
Sudden, rapid swelling
of the lips, mouth, throat or tongue
British Sign Language (BSL) speakers can make a video call to 999.
Deaf people can use 18000 to contact 999 using text relay.
Important: Do not use this form for emergencies
In the event of an emergency, do not submit this form as it may not be viewed immediately. Please call 999 for medical emergencies.
If you require medical assistance, please contact the practice, or call NHS 111.
We’ll ask you for:
- your first and last name, date of birth, sex, postcode, email and phone number
- if applicable, the details of the person you are completing the form on behalf of
You can also phone us on 01452 840228.
