Routine Appointment Request Patient Name First Last Date of Birth DD slash MM slash YYYY Mobile numberEmail address How you would like you appointment to be? Telephone appointment Face-to-Face appointment Consent I understand by requesting this appointment I will be placed on a waiting list which is not triaged by clinical need. This appointment is not for urgent clinical need and I am willing to wait up to 6 weeks for a routine appointment.Consent I understand that if, in the interim, I receive an appointment with a doctor, I will be removed from the waiting list.