Test - Oaktree Connect

Doctor / GP Surgery

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Name of GP / Surgery / Clinic / Hospital(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Medical Record Number (MRN)

Phone

Email Id(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

Type of Referral / Treatment Requested

Assessments

Recommendations & Treatments

Urgent?

Yes

Risk to Self / Others?

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 Information

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.(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.(Required)

Disclaimer: This disclaimer is subject to change and maybe modified from time to time.

This field is for validation purposes and should be left unchanged.