Test Doctor / GP Surgery Referrer InformationTitle(Required) First Name(Required) Surname(Required) Name of GP / Surgery / Clinic / Hospital(Required) Role/ DesignationClinicianNursePractise ManagerMedical AssistantMedical Records StaffOtherAddress Line 1(Required) Address Line 2(Required) Address Line 3(Required) City(Required) Country(Required) Postcode(UK) PhoneFax Email(Required) Website Patient InformationTitle(Required) First Name(Required) Surname(Required) Date of Birth MM slash DD slash YYYY Medical Record Number (MRN) Phone Email Id(Required) Address Line 1 Address Line 2 Address Line 3 City Country Postcode(UK) Referral InformationType of Referral / Treatment Requested Assessments Recommendations & Treatments Urgent? No Yes Risk to Self / Others? No Yes Reason for Referral (up to 300 words)Expectation from Referral (up to 300 words)Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant InformationI confirm that I agree to Oaktree Connect terms and conditions. This referral is made in good faith, no fees is payable/ paid to Oaktree Connect for the services requested via this website/app nor is there any monetary incentive for the referral.(Required) I confirm that I agree to Oaktree Connect terms and conditions. This referral is made in good faith, no fees is payable/ paid to Oaktree Connect for the services requested via this website/app nor is there any monetary incentive for the referral. I understand that a pre-authorisation and consent of the patient is required for referrals made to Oaktree Connect. I have ensured that if the patient is a minor/ lacks mental capacity to consent, the holder of power of attorney/ parent/ legal guardian has provided this consent.(Required) I understand that a pre-authorisation and consent of the patient is required for referrals made to Oaktree Connect. I have ensured that if the patient is a minor/ lacks mental capacity to consent, the holder of power of attorney/ parent/ legal guardian has provided this consent. Disclaimer: This disclaimer is subject to change and maybe modified from time to time.
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