Request an appointment with a Nurse or Healthcare Assistant

If you have a regular injection agreed with the hospital or practice and wish to book your next appointment please complete the attached form.

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.

Requests received after 16:00 will not be processed until the next working day.

Request an appointment with a Nurse or Healthcare Assistant - Haygarth

Section

The practice can send a text message to your phone with your appointment time. *
Appointment required (tick all that apply):
Annual review:

Please fill out an Asthma Review form.

Please fill out a Blood Pressure Review form.

Cervical screening:
Injections:
Have you had a shingles vaccine before? *
Have you suffered from shingles within the last 12 months? *
Are you under a consultant or having ongoing treatment/care at the hospital? *
Have you had a pneumonia vaccine before? *
Do you have an egg allergy? *
Do you have a latex allergy? *
Have you ever had an anaphylaxis reaction that your have been hospitalized for? *
Have you had a allergic reaction to any other vaccine? *
Have you been told when to have the appointment, for example, "in the next two weeks" or "in one month's time"? *
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