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 or post it to Sapphire Medical Clinics, 10 Harley Street, London, W1G 9PF along with any additional past medical history / records. Please ensure you provide the patients NHS number, email address, and your GMC number.

Download Referral Form
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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