Important: For care home use only

This form should only be completed by care home staff on behalf of their residents, who are registered patients of St James Medical Practice.

A member of our clinical team may call you to discuss the problem.

Where possible, home visit requests should be made before 10:30.

This form is not for individual patients. To request a routine appointment with a GP or nurse practitioner, please use the Get Help For Any Health Problem form.

Care Home Contact Request

This form should only be completed by care home staff on behalf of their residents, who are registered patients of St James Medical Practice.

Section

Reason for request:

About the Patients Problem

Please give as much detail as possible.
Any pain? *
Any fever? *
Any shortness of breath? *
Any diarrhoea? *
Any sickness? *
Is the patient alert and awake? *
Is the patient confused? *
Is the patient bed bound? *