(PT151) 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

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Home Visit Address

Street Address

Street Address Line 2

CityPostcode

Have you been to Fleet Street Clinic previously?

YesNo

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?

YesNo

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).

£426 per hour within a 3 mile radius from Fleet Street Clinic

£526 per hour outside a 3 mile radius from Fleet Street Clinic

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

Home Visit Request Form

Fees