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Patient Referral Form

Please complete in full the form below to refer a patient to our practice.

Patient Information

Referring Practioner Details

Our Referral guarantee

A clinician accepting a patient on referral will only undertake treatment they feel to be appropriate and that which lies within their competency.

If the accepting clinician feels that alternative or additional treatment is required, this will be discussed with both the referring clinician and the patient and consent obtained for an amended treatment plan and any costs involved.

Unless otherwise agreed with the referring clinician the accepting clinician will only carry out treatment in the capacity for which the patient has been referred to him/her.

THANK YOU FOR YOUR REFERRAL