Refer – Harrogate Harlow

Refer your patient

to Harrogate Harlow Private Healthcare Service

Referring your private patients or requesting a private appointment for diagnostic tests or treatment is fast and straightforward.

Refer a patient by…

Email Referral form

INFORMATION REQUIRED FOR A REFERRAL

In order to proceed with the referral we will ask you for some more information about your patient’s medical history. This may include some or all of the following:

Patient name
Date of birth
Gender
Home address and (if applicable) temporary UK address
Telephone number(s)
Email address
Funding details (including insurer’s name if funding through medical insurance)
Patient GP details (UK only)
Diagnosis
Current treatment and medications

REFERRAL FORM

Referring clinician’s details

Name *

GP practice or hospital *

Address including postcode *

Telephone number *

Clinician email address *

Patient details

Surname *

Forename(s) *

Date of birth *

Gender *

Patient home address including postcode *

Patient temporary UK address (if applicable)

Patient main contact telephone number

Patient other contact number

Patient email address

Referral details

Which service is the patient being referred to? (To select multiple hold ‘command’ buttton and click to select) *

Other information

Funding

If known, how will the patient’s treatment be funded?

3 + 1 = ?Please prove that you are human by solving the equation *

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OUR SERVICES

Visit our services for more information on the services we provide.