

Your form will be reviewed within 48 hours. You will be contacted by phone call by our reception team with a third party translator who can discuss your health requirements and take the most appropriate action for your needs.
You should not submit this form if the patient requires immediate treatment.
Call 999 if you have any of the following symptoms:
- Signs of a heart attack: chest pain, pressure, heaviness, tightness or squeezing across the chest
- Signs of a stroke: face dropping on one side, cannot hold both arms up, difficulty speaking
- Sudden confusion (delirium): cannot be sure of own name or age
- Suicide attempt: by taking something or self-harming
- Severe difficulty breathing: not being able to get words out, choking or gasping
- Choking: on liquids or solids right now
- Heavy bleeding: spraying, pouring or enough to make a puddle
- Severe injuries: after a serious accident or assault
- Seizure (fit): shaking or jerking because of a fit, or unconscious (cannot be woken up)
- Sudden, rapid swelling: of the lips, mouth, throat or tongue
- Labour or childbirth: waters breaking, more frequent intense cramps (contractions), baby coming, or just born
If you require contact out of hours and cannot wait until when the surgery is open please call 111