This is a private 3rd party referral form, to be used by health care professionals only.

If the referral us absolutely urgent, please ask the patient to call us within 24h of submitting this referral.

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Patient name *

First

Last

Address: *

Date of birth - please note you must be over 18. Minors must have a face to face consultation with a registered doctor or pediatrician - call us on 0141 404 6545 option 1 for a referral. *

Patient email address *

Best phone number to contact patient *

What is your (the referrer) name or clinic name *

What is your clinic email (so we can get hold of you for questions about the referral)

I confirm that we have obtained adequate consent from the patient to share these details and we are working in a patient care data sharing group for the benefit of the patient. This is a non NHS service and may require a £25 prescribing fee. per therapeutic area *

• Agree

How urgent is this referral *

• Immediate action required
• Within 24-48h
• Within 72h
• As soon as you can

Upload the referral form here - i.e. scan of blood/urine test results plus any consent forms or pertinent information *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Additional comments

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