Contact us Form Contact the practice Use this service for non-urgent general enquiries. We will respond within 2 working days during opening times. You can use this service if you: are registered at the surgery Who are you completing this form for? Yourself Someone Else What is your name? First Last What is the patients name? First Last What is your date of birth? DD slash MM slash YYYY What is the patients date of birth? DD slash MM slash YYYY What is your sex? Male Female Other What is the patients sex? Male Female Other What is Your Postcode? Postcode What is the patients Postcode? Postcode What is the patients relationship to you? Parent Guardian Spouse Carer Son Daughter Sibling Other What is Your Phone Number?What is Your Email Address? Named GP (if known) OptionalMessageConfirmation I confirm that my enquiry is not urgent, and it may take up to 2 working days before I receive a reply.