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Referral Form

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.)
STEP 1: PATIENT DETAILS
TITLE*:
FIRST NAME*:
LAST NAME*:
DATE OF BIRTH*:
ADDRESS:
POSTCODE:
TELEPHONE*:
STEP 2: PATIENT DETAILS
NAME*:
SPECIALTY*:
REFERRAL INFORMATION*:

(Maximum 1500 characters)
STEP 3: PATIENT DETAILS
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)
STEP 4: GP INFORMATION
GP / PRACTICE NAME*:
TELEPHONE*:
EMAIL ADDRESS:
   
  Please tick this box if you would like to print a copy of this referral for your own records.
  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
  Please tick to confirm the patient consents to their details being used.


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
   
 
Referring to BMI
   
  REFER TO A CONSULTANT
   
  BMI National Enquiry Centre
Unit 1, Cameron Court
Cameron Street
Hillington Park
Glasgow
G52 4JH


  GP Referral Hotline: 0808 101 0336
  Fax: 0141 300 2302
  Email: ebarr@nhs.net

  Call: Mon - Fri 8am - 8pm
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