GP Intervention Request - Drayton Medical Practice

All nursing and care home staff are able to submit a GP intervention request form on behalf of their residents, who are registered patients of Drayton Medical Practice, using the link that has be sent separately to the nursing / care home.

If you have any problems accessing this link, please contact Drayton Medical Practice on 01603 867532.

Please ensure all requests are received before 10:30.
Please coordinate all referrals with one point of contact for the GP surgery to call.
Please meet the visiting doctor and assign a member of staff for all ward rounds.

Which care home does the patient belong to?

Floor Optional

Senior Coordinator Name Optional

Your Name Optional

Your Position Optional

Date

Time

Patient Name

First Last

Patient Date of Birth

Phone Number

Your Email

Enter Email Confirm Email

About the Patient's Problem

Please tell us about the problem. If the practice is already aware of this problem, please tell us what has changed:

How long has this been a problem?

Observations Optional

How would you like us to deal with the problem?

Telephone

Appointment at the surgery

Visit

Readings

Please provide the readings below.

Systolic "Higher"

Please enter a number from 50 to 250.

Diastolic "Lower"

Please enter a number from 20 to 300.

Pulse

Please enter a number from 20 to 200.

Sats

Please enter a number from 60 to 100.

Temperature

Please enter a number from 30 to 45.

Blood Glucose

Please enter a number greater than or equal to 1.

Respiratory Rate

Please enter a number from 8 to 80.

Other Details

Sputum Colour Optional

Urinalysis Optional

Is the patient coughing or chesty?

Yes Optional

No Optional

Please specify if the condition is acute or chronic

Acute Optional

Chronic Optional

Further Information Optional

Email Optional

This field is for validation purposes and should be left unchanged.