Refer a Patient

Please fill in the form below to refer a patient to Sapphire Clinics. You will receive a confirmation email once the referral has been received.

Alternatively, you can download the form below and send to [email protected] or post it to Sapphire Clinics, PO Box 1436, Sunderland, SR5 9UE, along with any additional past medical history / records. Please ensure you provide the patients NHS number, email address, and your GMC number.

Referral Form

Guardian / Carer

Carer / Guardian *

Carer/Guardian Title *

Carer/Guardian First Name *

Carer/Guardian Last Name *

Carer/Guardian Email *

Carer/Guardian Phone Number *

Patient Details

Title *

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Gender *

NHS Number *

Patient Email *

Patient Phone Number *

Patient Location

Patient Address Line 1 *

Patient Address Line 2

Patient Address Post Code *

Patient Address Country *

Clinical Details

Reason for Referral *

Past Medical History

Current Medication

Known Allergies/Sensitivities

Please attach a copy of the ‘patient summary sheet’ from their medical record

Maximum upload size: 5MB

Referral Source

Please tell us your relation to the patient. *

You must select one of these options

Details of Referral Source (Your Details)

Name *

Email *

GMC Number *

NMC Number *

GPHC Number *

HCPC Number

Work Address Line 1 *

Work Address Line 2

Work Address Post Code *

Work Address Country *

Details of Patients GP

GP Name

GP Email

GMC Number

GP Address Line 1

GP Address Line 2

GP Address Post Code

GP Address Country

Privacy Disclaimer *

I understand that my information will be sent to Sapphire Medical Clinics and that they may contact me by phone, email or SMS going forward in relation to my treatment.

Overall Rating for this Location	Good
Are Services Well-led?	Outstanding

Refer a Patient

Guardian / Carer

Patient Details

Patient Location

Clinical Details

Referral Source

Details of Referral Source (Your Details)

Details of Patients GP

Sapphire Medical

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