Care Homes - Home Visit/GP Review Request Form

Please complete this form to allow effective triage for care home visit requests. Please submit requests by 10.30am each day so we can allocate a GP to visit prior to their afternoon surgery. If after this time, please call us to discuss. Visits will usually be made between 12 and 2pm. After completing this form, please call the practice on 01764 652283 to confirm that we have received it.

Please have the patient ready to be reviewed, ie in their room or a private area.

Todays date

Patient's name

Patient's date of birth

Patient's location

Please give a brief description of the problem

When did the problem start?For example hours/days/weeks/years ago?

Has this issue previously been reviewed, and if so, by whom?

How urgent is this issue? What is the expected timescale for review?

Could this be dealt with over the phone (ie medication queries)?

If you feel the patient is acutely unwell, please provide basic clinic observations if available. I.e. temperature, BP, heart rate, oxygen saturation.

Who is requesting this review? Ie patient, family member, care home staff. Please provide name.

Please confirm that you will call the surgery to confirm completion of this form.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to The Blue Practice • The Medical Centre, King Street, Crieff, Perthshire, PH7 3SA.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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