Ask reception a question

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Named GP (if known):

What is your question?

Would you like us to send you text messages?

Yes

No

Please note that the details you give will be used to update your medical records.

Confirmation

I confirm that my enquiry is not urgent, and it may take up to 2 working days before I receive a reply.

I confirm that I am registered at The White House Surgery, MORETON-IN-MARSH, Gloucestershire. If not, I will send to the correct surgery.

Tell us whether you accept cookies