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GP REFERRAL FORM

Please make sure you complete all sections of the form, then click on submit to send it via our secure email address.

Date of referral: *

YYYY

CCG: (Please select) *

Birmingham and Solihull (15E)

Sandwell and West Birmingham (05L) - (Note: West Birmingham only)

Name of GP: *

First Name

Last Name

Name of Practice: *

Address of Practice: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Practice phone no. *

Practice email address *

Patient's name: *

Patients NHS Number *

Patient's Date of Birth: *

YYYY

Sex: *

Patient's address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient's email address: *

Patient's phone no. *

Does the patient consent to the referral? *

Yes

Patient's ethnicity: *

Is it appropriate to write to the patient at home? *

Yes

Is the patient subject of legal proceedings? *

Yes

Is the patient a ‘looked after’ child/young person? *

Yes

Is the patient subject of a child protection plan? *

Yes

If yes, please give brief details: *

Please give details of the patient's presenting problems and reason for referral: *

FOR PATIENTS AGED UNDER 18 ONLY

Parent's name: *

First Name

Last Name

Parent's address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's phone no. *

We do not acknowledge receipt of referrals. The client will be contacted directly once we have an appointment available. Should you wish to check your referral has been received, please contact us on 0121 454 1116.

Thank you!