Request an Appointment with a Nurse Appointment required (tick all that apply): ECG Adult Vaccination/Injection Wound Management/dressing Cervical screening Please specify why you require the ECG.Which vaccine is needed? B12 Pneumococcal Shingles RSV (Respiratory syncytial virus) Goserelin (LHRH agonist – Hormone therapy for prostate cancer) Travel Please specify when it is due.Have you been invited to have the vaccine? Please note that we will check your records to confirm that you are due the vaccine you are requesting. If you are not eligible, we will not be able to offer you an appointment. Yes No Please specify when it is due.We do not offer a travel clinic at the surgery but are able to offer the following vaccines under the NHS: • Hepatitis A • Typhoid • Diphtheria/Tetanus/Polio These appointments must be booked 4 weeks in advance with the practice nurse to ensure timely order and delivery of the vaccine. We are unable to accommodate any requests less than 4 weeks and you may be directed to a private travel clinic. Please look at the following useful resource to check what vaccinations and precautions including malaria prophylaxis you may need for safe travel www.fitfortravel.nhs.uk/home If malaria prevention treatment is recommended then you should consult with your local pharmacy or a private travel clinic including vaccination for yellow fever or rabies. Please specify the date and destination of your travelIf you have an infected and/or painful wound which requires urgent care contact the surgery on 0208 863 3333 or call 111Please specify New wound Post-operative wound/dressing Follow-up dressing Please specify when the dressing/stitches removal is due. OptionalHave you received an invitation to have your smear Yes No The smear needs to be done mid-cycle, i.e. 10 to 20 days from the 1st day of your period. If you do not have regular periods, the appointment can be booked for any time. Please specify when the smear is due.Are you eligible for an annual smear? Yes No Please specify the reason.The smear needs to be done mid-cycle, i.e. 10 to 20 days from the 1st day of your period. If you do not have regular periods, the appointment can be booked for any time. Please specify when the smear is due.If you have not been invited and/or are not eligible for a smear, we will not be able to offer an appointment. Consent I understand that the practice may need to send me a secure online message about my appointment. I will check my emails. I agree to the practice sending me text messages including appointment times