Secretaries: I would like to change my NHS referral to a Private referral

Please complete this form if you would like to convert a current NHS referral into a Private referral.

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.

Full Name:

Date of Birth (DD/MM/YYYY):

Contact Number (Preferably Mobile):

Approximate date Referral was made:

Which Hospital Speciality was the referral too:

Where would you like to make your private referral too?

Would you like your NHS referral to be cancelled?

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.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.