(PT151) Home Visit Request Form

Home Visit Request Form
Please complete this form and our reception team will get back to you with a date and time of the home visit. Home visits are available Monday to Friday 9am-6pm.

If you are experiencing a medical emergency eg. chest pain, shortness of breath, suspected stroke or heart attack, please call 999 immediately.
Name (please complete one form per patient)

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: 000 0000 0000.
Email
example@example.com
Home Visit Address

Street Address

Street Address Line 2

CityPostcode
Have you been to Fleet Street Clinic previously?
When would you like the home visit to take place? (Please note, whilst every effort is made to accommodate your requests, we may not have availability on your requested date).
Please detail your presenting complaint, your current symptoms and the duration of symptoms (please provide as much information as you can to help the GP assess your concerns).
Please list your past medical history
What medications are you currently taking?
Do you have any drug allergies?
If you selected yes, please provide details of your drug allergies.
Is there any further medical information you would like the GP to know?
Please provide any details about the physical location of your home visit (dogs on premises, codes for security gates etc).
Fees
£600 per hour for GP visit

£350 per hour for Nurse visit

Please note that time is calculated from the clinician leaving Fleet Street Clinic and returning back to the Clinic again. The above fees exclude all prescriptions, medications, referrals and investigations.
I acknowledge that the above information is correct. I am aware that this request is for one patient only and should I need any other family members seen, I will complete a separate request. I am aware of the fees and consent to pre-payment before the home visit takes place. I am aware that all prescriptions, medications, referrals and investigations will incur an additional fee on top of the home visit fee.
PT151/QM/v1.0/i.02.2025/Public
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Home Visit Request Form

Fees