If you have been directed to use this form, please complete the questions below as fully as possible.

This is an overflow triage form. Your request will be reviewed today by a member of our clinical team. We will contact you to discuss your symptoms and, where appropriate, arrange a face-to-face appointment with the on-call GP or another suitable clinician.

Please note this form is intended for one medical concern only. If you have more than one issue to discuss, you may be asked to arrange a routine appointment for your additional concerns.

Please do not complete this form if any of the following apply:

• You (or the patient you are completing this form for) are under 12 years of age.
• You wish to discuss multiple or complex medical problems.
• You would prefer to book a routine appointment rather than be clinically triaged.
• You are requesting repeat medication or routine administrative requests.
• You (or the patient you are completing this form for) are experiencing a medical emergency, such as severe chest pain, difficulty breathing, signs of a stroke, or another life-threatening condition. If this is the case, call 999 immediately or attend your nearest Accident & Emergency (A&E) department.