Telephone: 0131 202 7651
enquiries@edinburghorthopaedics.com

Home
About
Who are we
Patient Information
Medicolegal
FAQs
Privacy
Links
Contact

ONLINE PAYMENT

Telephone: 0131 202 7651
enquiries@edinburghorthopaedics.com

Clinician Initiated Referral Form

For information about how we will use your personal details please see our Privacy Notice

Referral Details

Preferred Consultant*

Patient Details

Patient Name*

First Last

Patient Address*

Street Address Address Line 2 City ZIP / Postal Code

Patient Email*

Patient Phone Number*

Patient Date of Birth*

DD slash MM slash YYYY

Referral Clinician Details

Clinician Name*

First Last

Practice Name*

Practice Address*

Street Address Address Line 2 City ZIP / Postal Code

Clinician Email*

Clinician Phone Number*

Clinical Information

Details of your referral

Has the patient had related prior imaging*

Yes

Imaging Type*

XRay

Ultrasound

MRI

Imaging Location*

NHS Scotland

Spire Edinburgh

Edinburgh Clinic

Other

Date of XRay*

Date of Ultrasound*

Date of MRI*

Date of CT*

Imaging Location - Other*

Payment details*

Self Pay

Insured

Insurer Name*

Policy Number*

Authorisation Code*

Do you have additional files to send in support of this referral?*

Yes

File Attachment

Please include any relevant file attachment such as radiographs, clinical notes or photographs. We accept the following files: JPG, PNG, DOC, DOCX, PDF

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, Max. file size: 512 MB.

Signature

This form is being sent securely via the Encryptadata edForms service ensuring safe transmission of your data.

You are now in a secure area

Any data sent from this page are securely encrypted. The encrypted data are stored in an ISO27001 certified UK data centre.

This site uses cookies. By continuing to browse the site, you are agreeing to our use of cookies.

Home
About
Who are we
Patient Information
Medicolegal
FAQs
Privacy
Links
Contact