Request Form

You must be over 18 and reside in North Lincolnshire to qualify for this service.

This form allows you to request treatment from an NHS clinician without needing to go to your GP. This form can be used to ask for treatment by any method (e.g. telephone, in-person or by eClinic).

Please note that we cannot guarantee to get back to you immediately. Fields with an asterisk (*) are mandatory.