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Chapel Street Medical Centre NHS GP Surgery in Dudley

Care home contact request

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 Chapel Street Medical Centre.

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

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 Chapel Street Medical Centre.

Which care home does the patient belong to? *

Section

Name of person submitting this form: *

Job title: *

Reason for request:

Acute problem

Routine problem

Discharge following admission

About the Patients Problem

Duration of complaint: *

What have you tried to help?

For example, given analgesia, increased fluids.

Symptom of concern: *

Please give as much detail as possible.

Any pain? *

Yes

Any fever? *

Yes

Any shortness of breath? *

Yes

Any diarrhoea? *

Yes

Any sickness? *

Yes

Is the patient alert and awake? *

Yes

Is the patient more confused than normal? *

Yes

Observations

Blood pressure: *

Pulse: *

Respiratory rate: *

Oxygen saturation: *

Temperature: *

Is the patient on the GSF register? *

Yes

Is the family aware of the referral today? *

Yes

Next of Kin

Full Name: *

Phone Number: *

Relationship to you: *

Additional information:

If you are human, leave this field blank.

87 Chapel Street
Lye
Stourbridge
DY9 8BT

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01384 897668

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