COM - Appointment Request Form

Care Home Visit Request Form
Please note that this form is to be used to book routine Care Home visits with York Medical Group. In a medical emergency you should always dial 999. For any urgent request please continue to call the practice on 01904 439100. This form is only for use by staff at Care Homes linked to York Medical Group.
Care Home*
Patient Full Name*
NHS Number*
Gender*
Date of Birth*

DayMonthYear
Ethnicity*
Ethnicity Answer

Condition

Please select your primary symptom from the drop down list. This will help our clinicians to triage your appointment request.
Primary Area of Concern*
Cardiovascular Symptoms*
Dermatological Symptoms*
ENT Symptoms*
EYE Symptoms*
Gastrointestinal Symptoms*
General Review Options*
Genitourinary Symptoms*
Medication Review Options*
Musculoskeletal Symptoms*
Neurological Symptoms*
Palliative care Review Options*
Psychiatric Symptoms*
Respiratory Symptoms*
Systemic Symptoms*
Situation*
Background*
Assessment*
Blood Pressure: Pulse Rate: Saturations: Respiratory Rate: Temperature: Weight:
Recommend*
Annotate Image (Optional)
Take Photo (Optional)

Declaration
Please complete this section to confirm that you are requesting a ROUTINE visit ONLY. You should always contact 999 in a medical emergency. For URGENT visits please call the practice on 01904 439100. By signing you confirm that you have completed this form truthfully and to the best of your knowledge.
Staff Member Name*
I confirm that I have read and understand the Terms & Conditions as stated above.*
Signature of Staff Member*

Clear
Should be Empty:

Care Home Visit Request Form