Mental Health Appointment

If you are feeling suicidal or need a medication review, please DO NOT COMPLETE this form. Please contact the practice for a telephone appointment. We will contact you within 72 hours with your appointment details (this does not include weekends/bank holidays)

Last Updated: 25/05/2021

Your Details

Full Name *

Date of Birth *

Contact Telephone Number *

E-Mail Address

Appointment Details

Please choose your preferred appointment day below. We will try our best to book an appointment with the Mental Health Nurse on your preferred day of choice

Preferred Appointment Day *

Monday

Tuesday

Wednesday

Thursday

Friday

Any Day

Consent

Once we have received your request, we will contact you within 72 hours with your appointment details.

This form collects your name, date of birth, telephone number and e-mail. This is to confirm that you are registered with the practice and to allow us to contact you. *

Yes, I consent to the practice collecting and storing my data from this form.

Print Name *

Mental Health Appointment

Further Information