CLINICAL REFERRAL

Refer a patient

Thank you for referring your patient to Wye Sanctuary. Please provide some brief details below. A referral letter is welcome but does not need to follow a particular format. If you are referring for consideration of a specific intervention, please let me know which treatment you would like considered and include any relevant imaging information where available. You do not need to repeat information in the form if it is already contained within an attached referral letter.

Referral details

Referrer details

Your name

Professional role

Organisation / practice

Email address

Telephone number

Patient details

Patient name

Date of birth

Patient telephone number

Patient email address

Referral details

Reason for referral

Please briefly describe the clinical problem and what you would like me to help with.

Is there a particular intervention you would like considered?

For example: medial branch blocks, radiofrequency denervation, epidural injection or peripheral nerve block.

Relevant imaging or investigations

Please include any relevant imaging findings or investigation details if readily available.

Supporting documents

If you have a referral letter, imaging report or other relevant clinical information, please mention this in the referral. We can arrange for supporting documents to be sent securely if required.

I confirm that the patient is aware of and has consented to this referral.

Not sure whether to refer?

If you would like to discuss whether a referral is appropriate, or whether I can offer a particular intervention, please feel free to contact Wye Sanctuary before referring.

Discuss a referral