Webconsult - SAME DAY Appointment Request - Cwmbran Village / Llanyravon Surgery

This form should be used for SAME DAY (urgent) appointment requests only.

If your medical issue is not urgent, you can book an appointment up to two weeks in advance. Please call the surgery to book a routine appointment.

How Do I Make An Appointment

Check it's not an emergency.

Call 111 or 999 for urgent medical help if you have any of these as your request will not be seen immediately.

Crushing chest pain and tightness
New drooping on one side of the face, slurred speech, difficulty raising your arms, weakness or numbness on one side of your body.
Severe difficulty breathing
Heavy bleeding that won't stop
Severe injuries
Feeling suicidal, wanting to harm yourself, or other.

For sever mental health issues please contact NHS 111 and select option 2 to speak to a Mental Health & Wellbeing Practitioner.

If you use this form for Routine Appointment Request, Medication or Sick Note requests, the form will not be accepted and WILL NOT be processed.

Staff member initials (for surgery use only)

Is this request submitted for yourself or for someone you care for? - Please note the practice must have received written consent to discuss any patients’ medical needs who are over the age of 18+

On behalf of myself
On behalf of my child
On behalf of someone I care for or a family member

If you are completing this on behalf of a patient, please indicate your name below

Relationship to patient if you are completing this form on behalf of someone else

Full name of patient

D.O.B

Address

Telephone number (a mobile number is preferred)

We require all the following questions to be completed to allow us to process your request.

Please detail the reason you feel you require to be seen on the same day

If you would like to accompany this submission with an image to assist us with your request (for example of a lesion), please use the upload link below

What do you expect from this request?

Have you seen someone at the surgery for this problem?

Ydw

If yes, when was this?

How long have you had this problem?

Has the problem got worse in the past 5 day?

Ydw

If yes, in what way

Have you sought care and advice from another professional i.e.: Pharmacist?

Ydw

If yes, what professional did you see and detail what treatment you received

Please be aware that we are seeing patients face-to-face and you may be asked to attend the surgery. We ask that you are available during the day that you request your same day appointment.