Healthcare Professional Referral FormFor 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.* AcceptI can confirm the patient is registered with a Dorset GP.* AcceptI can confirm the patient is 16 or older.* AcceptYour Name* First Last Your contact number*Designation*Department & Location*E.g GP, ED PGH, Rheumatology RBH, # clinic DCHPatient GP Practice*James Fisher Medical CentreMoordown Medical CentrePanton Practice (Gervis Road Surgery)St Albans Medical CentreFarmhouse SurgeryHighcliffe Medical CentreChristchurch Medical PracticeStour SurgeryThe Marine Surgery and Oakridge SurgeryProvidence SurgeryWoodlea House SurgeryThe Grove SurgeryBeaufort Road SurgeryLittledown SurgeryShelley Manor & Holdenhurst Medical CentreSouthbourne SurgeryBanks & Bearwood Medical PracticeKinson Road Medical CentreTalbot Medical CentreVillage SurgeryLeybourne SurgeryDenmark Road Medical CentreWestbourne Medical CentreWinton Health CentreOld DispensaryOrchid House SurgeryPenny's Hill PracticeThe Quarter Jack SurgeryWalford Mill Medical CentreThe Cranborne PracticeThe Barcellos Family PracticeThe Verwood SurgeryWest Moors Group PracticeThe Birchwood PracticeCanford Heath Group PracticeThe Hadleigh PracticeThe Harvey PracticeHeatherview Medical Ctr.Lilliput SurgeryParkstone Tower PracticePoole Road Medical CentreWessex Road SurgeryThe Adam PracticeLifeboat Quay practice/formerly Carlisle HouseEvergreen Oak SurgeryFamily Medical Services (Dr Newman's Surgery)Poole Town SurgeryRosemary Medical Centre (Dorset)Cerne Abbas SurgeryFordington SurgeryMilton Abbas SurgeryPortesham SurgeryPoundbury Doctors SurgeryThe Prince Of Wales SurgeryPuddletown SurgeryQueens Avenue SurgeryThe Atrium Health CentreBlackmore Vale PartnershipGillingham Medical PracticeThe Apples Medical CentreThe Grove Medical Centre (Bute House Surgery & Newland Surgery)Yetminster Medical CentreWhitecliff Group PracticeEagle House SurgeryThe Bridges Medical PracticeCross Road SurgeryDorchester Road SurgeryRoyal Crescent & Preston Road SurgeryRoyal Manor Health CareWyke Regis and Lanehouse Medical PracticeBarton HouseBridport Medical CentreThe Charmouth Medical PracticeLyme Bay Medical PracticeThe Tollerford Practice - BeaminsterThe Tollerford Practice - Pound Piece, Maiden NewtonBere Regis SurgeryCorfe Castle SurgerySandford SurgerySwanage Medical PracticeWareham SurgeryThe Wellbridge PracticePlease select your preferred physiotherapy team*Royal Bournemouth and Christchurch NHS Foundation TrustPoole Hosptial NHS Foundation TrustDorset County Hospital - Dorchester (Temporarily Weymouth)Dorset County Hospital - WeymouthDorset HealthCare - BlandfordDorset HealthCare - BridportDorset HealthCare - Lyme RegisDorset HealthCare - PortlandDorset HealthCare - ShaftesburyDorset HealthCare - SherborneDorset HealthCare - St LeonardsDorset HealthCare - SwanageDorset HealthCare - WarehamDorset HealthCare - WimbornePLEASE ATTACH DETAILS OR complete belowMax. 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 numberDoes the patient consent to phone messages at this number? Yes NoPatient Email Address Enter Email Confirm Email Does the patient consent to use of this email to send details about their appointment? Yes NoReason for referral: Please complete details*HiddenDate DD slash MM slash YYYY