eConsult Form Demo Please do not use this form to submit information as it is only for demonstration purposes and does not store any information.Please note: Submitted forms are only viewed and processed during normal GP working hours. Forms submitted over the weekend and on bank holidays will not be seen by a clinician until the next working dayPlease DO NOT complete this form if you have any of the symptoms below. Please phone 999. Possible heart attack/stroke Severe chest pains Severe breathing difficulites Severe allergic reation or anaphylaxis Fitting Drowsiness, confusion or unconsciousness Severe burns or scalds Suffered trauma or a head injury Please DO NOT fill in this form if you have the following symptoms. Please contact 111 for assessment of Covid-19. a high temperature – this means you feel hot to touch on your chest or back (you do not need to measure your temperature) a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) a loss or change to your sense of smell or taste – this means you've noticed you cannot smell or taste anything, or things smell or taste different to normal Please tick to confirm you do not have any of the symptoms listed above * I DO NOT have any of the above symptomsPrivacy Policy This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. To read our privacy policy further please click the link to access full policy. GP eSolutions Privacy Policy Please tick to confirm* I consent to the practice collecting storing and updating my data from this formName of parent/guardian (if filling in form on behalf of patient under 16yrs of age. Full Name* First Last Date of Birth* DD slash MM slash YYYY Please tick if completing this section on behalf of a patient under 16 years of age. I can confirm that I am the parent/guardian responsible for the patient I am completing this form on behalf of.Address* Street Address Address Line 2 City Post code Phone*Email You will receive a confirmation email when submitting this form.The practice will contact you usually within TWO working days regarding your online form.Please select which service you require today. (You can select more than one option)* GP consult Nursing consult Admin query Pharmacy/Medication query Request for medication Request for fitnote Other Admin QueryQuery information*Pharmacy QueryQuery information*OtherPlease type any other information here. GP ConsultPreferred Clinician*No preferenceDr BrownDr YasminDr Gillspie(This is usually the quickest response)Reason for contacting us*How many days have you had these symptoms?* Self care - (visited pharmacy, tried over the counter medication)What would you like from the practice(i.e telephone call etc)Please state any times your are NOT available for a call* If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3 - 5MB) for the GP/Nurses attention. Pollokshaws Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be FILED into your medical records..Accepted file types: png, jpg, jpeg, Max. file size: 3 MB.Request for MedicationPlease allow TWO working days for the processing of prescriptions. If you request is urgent please let us know in the box below, or contact the surgery direct.Medication required.*If you would like your prescription to go to a local pharmacy to us, please leave the name in the box below.* Request for FitnotePlease note we are unable to email sicklines at present. We advise that you or a representative can collect sicklines from the practice.Reason for the fitnote*Date from* DD slash MM slash YYYY Date to* DD slash MM slash YYYY Nursing ConsultPreferred Nurse*No preferenceNurse ElaineNurse MaryNurse Rhona(This is usually the quickest response)Reason for contacting us*How many days have you had these symptoms?* Self care - (visited pharmacy, tried over the counter medication)What would you like from the practice(i.e telephone call etc)Please state any times your are NOT available for a call* If your request is regarding a visible issue i.e rash or bruising, you can attach a photograph (max 3 - 5MB) for the GP/Nurses attention. Pollokshaws Medical Centre would like to advise patients that when asked to send photographs for the purposes of assessment, these photographs will be FILED into your medical records..Accepted file types: png, jpg, jpeg, Max. file size: 3 MB.ConsentPLEASE TICK TO CONFIRM* I agree to the practice contacting me for feedback on the form/processPLEASE TICK TO CONFIRM (Please note our mailbox is not continually manned)* I CONFIRM THAT I DO NOT HAVE ANY OF THE RED FLAG SYMPTOMS LISTED ABOVE
