Request a private referral

If you choose to be referred to a private provider for healthcare, there is no charge for the actual referral letter. However, you will have to pay for your healthcare at the private service, either through existing insurance, or from your own pocket. Please check you can pay for your consultations and treatment before requesting a private referral.

If your insurance company requests a form to be completed by the GP in addition to completing the referral, a charge will apply. Please email us a copy of the form and we will let you know the fee for completion.

If you have not spoken to a GP about your issue, you may need to have an appointment before the referral can be completed. We will let you know if this is the case.

Last Updated: 15/05/2023

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Named GP (if Known)

Referral Request

What service would you like to be referred to? Please provide as much information as possible, including department, hospital or setting name and address, and a consultant name if applicable. *

Why do you need this referral? *

Have you already spoken to a doctor about this issue? If so, please provide an approximate date

Will you be paying yourself or through insurance? *

Self-pay

Insurance

If paying through insurance, please provide the name of your insurance provider and your policy number or claim number

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. The information on this form will be stored in our website provided by My Surgery Website for up to one month before being deleted. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

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Request a private referral

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