Secretaries: Referral Status Update

Please complete this form if your referral was NOT an electronic NHS ereferral (also known as choose & book). For this kind of referral you would of received referral paperwork or a text containing a reference number and password. These referrals can be tracked via the online tracking service.

If your referral is NOT a choose and book referral and you have contacted the relevant hospital speciality then please complete this form.

Please do not write any symptom queries on this form. Any symptom queries or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. Please DO NOT call before 5 working days as you will not receive a status update from reception or the administrative team. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Address:

What was your referral for? Which speciality or for what problem?Please detail the speciality and location e.g. Dr Smith, Warwick Hospital

Are you a new patient for this clinic or a follow-up patient?

If a NEW patient when was the referral approximately made? If a FOLLOW-UP patient when were you approximately supposed to of been seen?

I confirm I have contacted the relevant speciality to enquire about the status of my referral.

Please document what they said regarding your referral/appointment or document what issues you have been having

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

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