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Wilmslow Road Medical Centre 156 Wilmslow Road, Manchester, M14 5LQ | Tel: 0161 224 2452

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Request an appointment with a Nurse

Tell us when you want your appointment and we will reply to you with a time; once we receive this form we will process it within 4 working hours.

Are you completing this form on behalf of

Yourself

Someone else (e.g. a child or dependent)

About the Patient

Patient Name

First Last

Patient Postcode

Patient Date of Birth

Day

Month

Year

Patient Sex

Male

Female

Other

About You

Your Relationship to Patient

Name

First Last

Postcode

Date of Birth

Day

Month

Year

Sex

Male Optional

Female Optional

Other Optional

Your Phone Number

Your Email

Enter Email Confirm Email

Request Details

The practice can send a text message to your phone with your appointment time.

I agree to the practice sending me text messages including appointment times

I do not agree to the practice sending me a text message with my appointment time

Appointment required

Blood test

Blood pressure check

ECG

Vaccination

Asthma review

COPD review

Diabetes review

Wound management/dressing

Cervical screening

Other

(Tick all that apply)

Please specify what other appointment

Have you been told when to have the appointment, for example, "in the next two weeks" or "in one month's time"?

Yes

No

When does the appointment need to be?

Tell us when you are available to have an appointment

Tell us when you are available to have an appointment in the next three weeks

Messaging Consent

I understand that the practice may need to send me a secure online message about my appointment. I will check my emails.

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