Dr Cole & Partners

Blackfield Health Centre

Online Prescription Request

BP Reading Form


To submit a home BP Reading, please complete and submit the form below.

Which surgery are you registered at?

Waterside

Blackfield

Please tick this box before submission to acknowledge that this form is being sent un encrypted via the world wide web

Stop Date:

Yes

No

Yes

No

Smoker Ex-Smoker Never Smoked Electronic Cigarette (Vapes) I do not wish to have my BP taken Home BP Reading

Mobile Number

Home Tel Number

Do you wish to receive text messages from us?

Email Address

Do you wish to receive emails from us?

Name

Date of Birth

Weight Height

Smoking Status

Blood Pressure Reading

If you are not happy to tick the box above please drop your BP reading into the surgery.

Or

Dr Cole & Partners


RED & GREEN PRACTICE

Waterside & Blackfield GP Surgery   


Waterside (Hythe) & Blackfield Health Centres