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PRE INSTALLATION SURGERY SERVICE REQUEST FORM

Complete this form to apply for leaflet racks for your surgery with additional poster boards. If you would like to apply for the service without poster boards, please follow this link. Alternatively, if you would like to download a .pdf file to print out and post follow this link.

Note that after submission of this form, we will send you a confirmation email to let you know the application was successful. If you do not receive this email within 15 minutes, please call us on: 01489 860000.
Section A: Practice Details
Practice name:
Address:
Town:
County:
Postcode:
Telephone number:
Fax number:
Section B: Contact Details
Contact name:
Position:
Email address:
Tel. no.:
Section C: Surgery Details
In the boxes provided please enter the number of the following in your surgery:
Doctors: Nurses: Nurse prescribers:
What clinics are currently run in your surgery and what quantities of patients subscribe to these?
Allergy: Diabetes: Travel clinic:
Anti-smoking: Nutition & diet: Vaccination:
Asthma: Heart helath: Well man:
Baby clinic: STD: Well woman:
How many registered patients do you have?
Is there a particular demographic lending (Age)?
18-29 30-39 40-49 50-59 60+
What are your surgery hours?
Open AM: Close AM:
Open PM: Close PM:
Half days / Regular closures:
(please state days and times)
What parking facilities would be available to out field staff?
Surgery car park: Off road parking: Metered Parking:
Roadside spaces: No parking:    
In the space below please detail availability of spaces and distance to the surgery:
Section D: Rack location
Where would you like the rack to be installed?
  • Please note that the rack cannot be installed in treatment rooms.
  • Please check that appropriate wall space is available (H107 × W67 × D11cms )
Waiting room: Reception: Foyer:
Section E: Poster Boards
With each rack installation you can have 2 poster boards installed.
( Size 420mm × 594mm × 25mm ) Would you like poster boards installed?:
yes: no:
if so, how many?
Section F: Health & Safety
Is drilling into walls permitted in your surgery building?
yes: no:
Are you aware of any asbestos in your building that our installer could come in to contact with when drilling the walls?
yes: no:
When visiting your surgery would our staff be entering a dangerous area where they may have to take precautionary measures?
yes: no:
Section G: other
Please provide any further information that may be relevant in the space provided: