This is a private 3rd party referral form, to be used by health care professionals only.

If the referral us absolutely urgent, please ask the patient to call us within 24h of submitting this referral.

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Patient name
I confirm that we have obtained adequate consent from the patient to share these details and we are working in a patient care data sharing group for the benefit of the patient. This is a non NHS service and may require a £25 prescribing fee. per therapeutic area
How urgent is this referral
Click or drag files to this area to upload. You can upload up to 5 files.