Referral Form | Ramsay Health Care UK

Patient Referral Form

This form is to be completed by the referrer, this is not for a patient to complete.

Please upload a copy of the referral letter, multiple files can be added (at the same time or one at a time) and will be attached to the new email.

All file formats accepted

No files selected

Is this referral urgent? E.g cancer, cardiac or services equivalent to the NHS two week wait. Tick if yes:

Patient Details

Patient First Name *

Patient Surname *

Your e-mail address *

Patient NHS Number *

Referring GP *

GP Practice *

Additional patient information i.e. additional patient needs, co-morbidities, recent results

If named consultant is unavailable within 72 hours, can we forward a referral to another consultant with the same speciality? Tick if yes:

Please confirm your hospital selection: *

I confirm this patient information is being transferred in accordance with the Data Protection Act 2018, as amended from time to time. *

This electronic referral email will go to our appointment team for processing and will be held for a period of three months. Your private patient will be contacted by our bookings team to arrange an appointment date and time.

We use SSL protocol to secure the transfer of patient data and have installed an SSL Certificate (provided by DigiCert® with Extended Validation (EV)) which confirms the highest level of authentication available among SSL certificates.

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Patient Referral Form

This form is to be completed by the referrer, this is not for a patient to complete.

Please upload a copy of the referral letter, multiple files can be added (at the same time or one at a time) and will be attached to the new email.

Patient Details

Important Information

Contact details

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