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Questionnaire template

Medical Practice Contact Form

A non-urgent contact form for patients or carers to send requests to a medical practice and say how to be reached.

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Other · Contact forms. All Other templates

Questions in this template

Your Details

  1. Use this form to send a non-urgent request to the practice. A member of our team will get back to you.

  2. This form is not monitored around the clock. If you have a medical emergency, call your local emergency number straight away.

  3. What is the patient's full name?

    Open answer

  4. In what year was the patient born?

    A number from 1900 to 2026

  5. Is the patient already registered with our practice?

    Choose one:

    • Yes, existing patient
    • No, new patient
    • Not sure

  6. Who are you contacting us about?

    Choose one:

    • Myself
    • Someone I care for

  7. What is your relationship to the patient?

    Condition: Shown when writing on behalf of someone else

    Choose one:

    • Parent or guardian
    • Partner or spouse
    • Other relative
    • Carer
    • Other

Your Request

  1. What is your request about?

    Choose one:

    • Booking or changing an appointment
    • A repeat prescription
    • Test results
    • A referral or letter
    • Billing
    • A general question
    • Other

  2. What is your request about?

    Condition: Shown when 'Other' is chosen

    Open answer

  3. How soon do you need a reply?

    Choose one:

    • Within 1 working day
    • Within a few days
    • There is no rush

  4. Briefly describe your request. Please include only the details we need to help you.

    Open answer

How to Reach You

  1. How would you like us to get back to you?

    Choose one:

    • Phone call
    • Email
    • Text message
    • Patient portal message

  2. Please give the phone number or email address we should use.

    Open answer

  3. When is a good time to call you? Select all that apply.

    Condition: Shown when a phone call is preferred

    Choose any that apply:

    • Morning
    • Afternoon
    • Evening
    • Any time

Consent

  1. Do you agree to the practice contacting you about this request using the details you have given?

    Choose one:

    • Yes
    • No