New Patient Referral – KSJ

New Patient Appointment (KSJ)

Please don’t use this form if you have not secured an appointment or discussed all elements of the process including all costs with the patientConsultations are undertaken remotely and patients should also be made aware of this.

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Patient Title
Patient Name
Does patient have any pre-existing conditions, illnesses, allergies or disabilities?
Complete the section below if you answered Yes.
Anything else you feel may be relevant and/or helpful to know.
Treatment for Menopause or Perimenopause
Have you outlined the potential cost of diagnostics?
Average cost of diagnostics is around £500 for a menopause profile, full thyroid profile plus adrenal stress profile.
What is the patient's intention, solely so that we can manage their expectations??
Please use the 'additional comments' section above to expand on this if needs be.