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

Patient Details

Patient Location

Clinical Details

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)

Details of Patients GP

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