Ballochmyle Medical Group eConsult

Please note Submitted forms are only viewed and processed during normal GP working hours. Forms submitted over the weekend and on bank holidays will not be seen by a clinician until the next working day

Please DO NOT complete this form if you have any of the symptoms below. Please phone 999.

Possibly heart attack/stroke
Severe chest pains
Severe breathing difficulties
Severe allergic reactionor anaphylaxis
Fitting
Drowsiness, confusion or unconsciousness
Severe burns or scalds
Suffered trauma or a head injury

Please tick to confirm you do not have any of the symptoms listed above*

I DO NOT have any of the above symptoms

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

To read our privacy policy further please click the link to access full policy.

Ballochmyle Medical Group Privacy Policy

Please tick to confirm*

I consent to the practice collecting storing and updating my data from this form

Please tick if completing this section on behalf of a patient under 16 years of age.

I can confirm that I am the parent/guardian responsible for the patient I am completing this form on behalf of.

Name*

First Last

Date of Birth*

Name of parent/guardian (If filling in form on behalf of patient under 16yrs of age)

Address*

Address line 1 Address line 2 City Post Code

Phone Number*

Please select which service you require today.*

GP/ANP consult

Nursing consult

Admin query

Pharmacy/Medication query

Request for fitnote

Other

GP/ANP Consult

Reason for contacting us*

How many days have you had these symptoms?*

Self care - (visited pharmacy, tried over the counter medication)*

What would you like from the practice?*

If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3MB) for the GP/Nurses attention. Ballochmyle Medical Group Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be FILED into your medical records. Please DO NOT send any images of private sensitive areas of the body.

If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3MB) for the GP/Nurses attention. Ballochmyle Medical Group Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be FILED into your medical records. Please DO NOT send any images of private sensitive areas of the body.

Drop files here or

Max. file size: 3 MB, Max. files: 5.

Nursing Consult

Reason for contacting us*

How many days have you had these symptoms?*

Self care - (visited pharmacy, tried over the counter medication)*

What would you like from the practice?*

If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3MB) for the GP/Nurses attention. Ballochmyle Medical Group Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be FILED into your medical records. Please DO NOT send any images of private sensitive areas of the body.

Drop files here or

Max. file size: 3 MB, Max. files: 5.

Admin Query

Query information*

Pharmacy Query

Query information*

Request for Fitnote

Please note we are unable to email sicklines at present.
We advise that you or a representative can collect sicklines from the practice.

Reason for the fitnote*

Date from*

Date to*

Other

Please type any other information here.*

Consent

Consent*

I agree to the practice contacting me for feedback on the form/process*

Consent*

I confirm that i do not have any of the red flag symptoms listed above*

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Name

This field is for validation purposes and should be left unchanged.