Get Help for a Medical Problem – Chorlton Family Practice

If you are filling in this form on behalf of the patient, we are unable to discuss confidential patient information about people aged 18 or over with third parties without prior written agreement.

If there is no written agreement in place, please ask the patient themselves to complete this form.

About the Matter

Please provide as much information about the problem as you can, to enable us to help you as best we can. For instance, if you have pain, where is it, what does it feel like, does it travel anywhere else? Have you had any other symptoms that you think might be relevant? Have you tried anything to help with your problem so far?

If you’re not sure, it’s helpful to tell us whether it’s been days, weeks, months or years.
The practice can send a text message to your phone with your appointment time. *
Terms & Conditions *
If you think it would be helpful, please upload photo(s) of your condition.
Maximum upload size: 67.11MB