Mental Health Form - Waterfront Medical Centre

If you are feeling suicidal or need a medication review, please do not complete this form. Please contact the practice for a telephone appointment.

We will contact you within 72 hours with your appointment details (this does not include weekends/bank holidays).

Personal Details

Full Name

Date of Birth

Address

Contact Number

Further Information

Please choose your preferred appointment day/s below. We will try our best to book an appointment with the Mental Health Nurse on your preferred day of choice

Consent

This form collects your name, date of birth, other personal information and medical details. This is to confirm you are registered with the practice, to allow Waterfront Medical Centre to contact you, and to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy for more information on how we protect and manage your submitted data. I consent to Waterfront Medical Centre collecting and storing my data submitted via this form.