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. Please provide the patients NHS number, email address, and your GMC number.

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