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Make a Healthcare Professional Request?

Make an Appointment

01952 460414

Request an Appointment Online

Healthcare Professional Request

Required fields are marked with an asterisk (*).

Date

Please select from the drop down below and tell us how we can help you…

I would like to request a Patient Brief Summary (Professionals only non-urgent)

I would like to request Other… (Professionals only non-urgent)

If Other please provide details

First Name*

Surname*

Date of Birth*

Patient Email address

NHS No.*

Patient Contact Telephone Number

Please complete the section below before we can process your request…

Who is requesting this information?

Information required/Reason for request*

Department/Service/Hospital Name*

Requester Name*

Requesters Job Title*

Requester contact number *

(and EXT if applicable)

Requesters email address*

*Please make sure all Mandatory fields have been completed

*Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. 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

Are you human?*

This field should be left blank

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Please note this form is not to be used for the following purposes:

Medical matters, Prescription requests, Patient Access requests, Appointment requests or Complaints. Medical matters cannot be dealt with via this form. If you have a query regarding a medical matter please telephone reception to make an appointment to see the appropriate person.

Other forms available

Register as Patient

Please visit our Patient Registration page and fill in the health questionnaire to register as a patient at Teldoc.

Change of Address

Please visit our Change of Name Form to update your details

Provide Feedback

Please visit our Feedback Form to provide feedback, make a suggestion or complaint.

More forms

Please visit the How Do I Portal for more forms

Find out more...

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Latest News at the Surgery

All the latest news from Shifnal & Priorslee Medical Practice, the NHS and other health services

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Vaccination Information

All the latest vaccination clinic dates and locations and latest vaccination news from Teldoc PCN and NHS

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Visit the How Do I Portal

Visit the How Do I portal for information on how to make an appointment, register at the practice and change your details

Register for Online Access

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01952 460 414

Haughton Road, Shifnal, Shropshire, TF11 8DD

Gatcombe Way, Priorslee, Telford, TF2 9GZ

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