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.

If you would rather send a written referral or would like to send more detailed past medical history/medication record, please send this to Sapphire Medical Clinics, 10 Harley Street, London, W1G 9PF

Referral Form (New)

If you are human, leave this field blank.

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 City *

Patient Address County *

Patient Address Post Code *

Patient Address Country *

Clinical Details

Reason for Referral *

Past Medical History

Current Medication

Known Allergies/Sensitivities

Referral Source

Please can you tell us if you are a GP or a Consultant?

Please can you tell us if you are a GP or a Consultant? *

Consultant

Details of Referring Consultant

Consultant Name *

Consultant Email *

GMC Number *

Hospital Address Line 1 *

Hospital Address Line 2

Hospital Address City *

Hospital Address County

Hospital Address Post Code *

Hospital Address Country *

Details of Referring GP

GP Name *

GP Email *

GMC Number *

GP Address Line 1 *

GP Address Line 2

GP Address City *

GP Address County

GP Address Post Code *

GP Address Country *

Privacy Disclaimer *

I confirm that I have read and understood this website's Privacy Policy and Terms and Conditions and have the patient's consent to share their information.

This information will be used to create a PKB account and stored securely on the PKB server, a trusted partner of the NHS