NIGHTINGALE PATIENTS – CLICK HERE TO SUBMIT A TRIAGE REQUEST

From Monday the 16th of October, Nightingale medical centre will be moving to a total triage system. This means, to access an appointment you will need to fill in a triage request. Once the request has been triaged we will contact you with the outcome, this may be an appointment with a clinician or it

Dr Laliwala & Partners

Need help with a non-urgent medical or admin request? Contact us online.

Dr Laliwala & Partners > Your Record > Keep us up to Date > Register as a Carer Form

Register as a Carer Form

Which Practice are you registered with?

Carer Details

Your First Name *

Your Last Name *

Your Email *

Enter Email

Confirm Your Email *

Confirm Email

Your Date of birth *

Please use format day/month/year e.g. 12/05/1979

Your Phone Number *

Your Address

Town/City

County

Postcode

Country

Details of Person You Care For

First Name *

Last Name *

Date of birth *

Please use format day/month/year

Address of person you care for

Town/City

County

Postcode

Country

What relationship to you is the person you care for?

Is the person you care for a patient at this surgery?

Yes

Privacy 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.

I consent to the practice collecting and storing my data from this form.

NIGHTINGALE PATIENTS – CLICK HERE TO SUBMIT A TRIAGE REQUEST

Dr Laliwala & Partners

Register as a Carer Form

Carer Details

Details of Person You Care For

Privacy Policy

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