Diabetes & Endocrinology referral.

Only GP or Specialist referrals will be accepted using this form. Please complete all fields or requests may be rejected. It is advisable that your patient attends with formal reports of most recent cardiac imaging and/or clinical correspondence.

At present our clinical facilities are on the first floor, with only stair access. We apologise if we are therefore unable to accommodate your patient.
Terms and Conditions
Clinic Fees

Patient Name

First Name

Last Name

10-Digit CHI Number

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient Email

Patients will receive appointment details and a copy of their clinical letter to this address.

Patient Mobile Number

Appointment details/reminders will be sent to this number.

(###)

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Clinical Details of Request

Referring Clinician's Name

First Name

Last Name

GMC Registration No.

Registered Clinic Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Clinician/Clinic Email

Personal emails will not be accepted. Please provide your NHS or official Private Practice email address. Clinical correspondence will be sent to this address.

Consent, Chaperone & Accessibility

Please tick where the answer is 'yes'.

Does the Patient provide consent for their correspondence to be emailed to them and their referring Practitioner?

Is the Patient aware of the cost of the service and any additional consultation or test that may be advised?

The Patient has requested a chaperone.

The Patient is able to manage one flight of stairs to the clinical floor.

Payment Method

Self-paying

Private Insurance (BUPA, AXA, Vitality, Aviva, Cigna)

Diabetes & Endocrinology referral.

HoURGLASS WELLBEING CLINICS & TRAINING ACADEMY

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