Referral Form

Prices & Appointments: 0808 101 0337

Please complete all required fields, and provide as much detail as is relevant to ensure an effective referral. (All patient information sent is only used for the purposes of the referral and will not be stored by BMI Healthcare.)

TITLE*:
FIRST NAME*:
LAST NAME*:
DATE OF BIRTH*:
ADDRESS*:
POSTCODE*:
TELEPHONE*:

NAME*:
SPECIALTY*:
REFERRAL INFORMATION*: (Maximum 1500 characters)

PAST MEDICAL HISTORY: (Maximum 500 characters)
CURRENT MEDICATION: (Maximum 500 characters)
ANY RELEVANT TEST RESULTS/LETTERS: (Maximum 500 characters)
ATTACH ANY PATIENT NOTES:	(please use .doc, .pdf, or image file formats only)

GP / PRACTICE NAME*:
TELEPHONE*:
EMAIL ADDRESS*:

Please tick if you are happy for us to telephone you if we have difficulty contacting you via your preferred method, or need to clarify anything on your referral form By pressing submit your referral form will go to one of our specially trained Helpline advisors. Following receipt of the referral form, your patient will be contacted by one of our helpline advisors to arrange a suitable appointment date and time. Alternatively, you may wish to fill in the downloadable referral form and fax it for added security.

Fields marked* must be completed


	REFER TO A CONSULTANT

	BMI National Enquiry Centre Unit 1, Cameron Court Cameron Street Hillington Park Glasgow G52 4JH
	GP Hotline: 0808 101 0336
	Fax: 0141 300 2302
	Email: ebarr@nhs.net
	Call: Mon - Fri 8am - 8pm

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BMI Healthcare Limited - Part of General Healthcare Group
Registered in England Number 2164270

Registered Office
4 Thameside Centre, Kew Bridge Road, Brentford,
Middlesex, TW8 0HF

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