Healthcare Professional Referral Form

For any of the conditions listed below, please refer your patient to the specialist services the usual way:
- Neurological condition (such as Stroke or MS).
- Gynaecological condition (such as prolapse or incontinence).
- Respiratory condition (COPD or cystic fibrosis).
- Pregnancy related conditions.
- Paediatric conditions.
Please confirm you are not referring for any of the above conditions.*
- Accept
I can confirm the patient is registered with a Dorset GP.*
- Accept
I can confirm the patient is 16 or older.*
- Accept
Your Name*
First Last
Your contact number*
Designation*
Department & Location*
E.g GP, ED PGH, Rheumatology RBH, # clinic DCH
Patient GP Practice*
Please select your preferred physiotherapy team*
PLEASE ATTACH DETAILS OR complete below
Max. file size: 250 MB.
Patient Name*
First Last
Patient Date of Birth*
DD slash MM slash YYYY
NHS Number (If known)*
Patient Address
Street Address Address Line 2 City ZIP / Postal Code
Patient preferred contact phone number
Does the patient consent to phone messages at this number?
- Yes
- No
Patient Email Address
Enter Email Confirm Email
Does the patient consent to use of this email to send details about their appointment?
- Yes
- No
Reason for referral: Please complete details*
Hidden
Date
DD slash MM slash YYYY