If you are due an annual asthma review please answer the following questions and submit this form to us. If your symptoms are deteriorating or you have any concerns, please make an appointment to see the respiratory nurse or a Doctor as well.
Note: By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.
If you are not, did you know there is an online demonstration on the Asthma UK website or you could pop in and see our practice nurse for more advice. https://www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/
If 'Yes', please answer the following:
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
The Apples Medical Centre
East Mill Lane, Sherborne, Dorset, DT9 3DG.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.