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Membership Number*
Patient Initials*
Patient Surname*
Dependant Code (appearing on membership card)*
Patient Date of Birth (yyyy-mm-dd)*
Contact details (authorisation number will be send to this number or email address)*
Details of Specialist Consulted
Initials and Surname of Specialist to be consulted*
Practice Number of Specialist*
Details of Referring Doctor *
Name of Hospital where patient will be admitted
Practice Number of Hospital where patient will be admitted
Date of Consultation/Treatment/Admission?*
Contact Number of Specialist
Practice Number of Specialist*
Diagnosis
Practice Number of Referring Doctor
Contact details of Referring Doctor
ICD10 Code
Tariff Code if admitted to Hospital
Copy of Referral letter
Max. file size: 512 MB.
Copy of Referral letter
Max. file size: 512 MB.

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