Secretaries: Private Referral Request

Please complete this form if you would like a private referral from your GP. Please document the key information to help your GP and our adminstrative team. They may contact you for further information if necessary.

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 10 working days to complete. Please DO NOT call before 10 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):

Reason for referral:

Have you been seen by anyone regarding this issue before?

Who would you like to be referred too (Location & Department needed)e.g. Dr Smith Cardiology at Nuffield Warwickshire Hospital

I confirm I am happy to be contacted by the surgery (text or call) on the mobile number provided if deemed necessary and that the information given in this form is accurate.

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.