New Patient Referral

New Patient Referral & Appointment

Please do not use this form if you have not secured an appointment or discussed all elements of the process including all costs with the patient. Please use this form if you wish to simply refer an enquiry – they should enter your name in the ‘referring agent’ field at the bottom.

A small red '*' symbol denotes a required field.
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Patient Title
Patient Name
Patient's Symptoms (Please check each symptom/condition below that applies)
Does patient have any pre-existing conditions, illnesses, allergies or disabilities?
Complete the section below if you answered Yes.
Has patient received any hormone treatment?
If products/supplements/vitamins are sourced, please provide details below.
An appointment will be allocated automatically at a time/day specified above but can be rearrange by the patient if not convenient. A confirmation plus details will be emailed to the patient, along with an invoice from our merchant 'Stripe' which should be paid in order to secure the appointment.
Have you outlined the process and costs to the patient? Please tick all that you have discussed.
The initial phase of treatment (from first consultation to 3-month review) is the most costly phase, averaging around £800 in total. The doctor will determine each review period and ongoing diagnostic requirements based on a patient's individual treatment needs.
What is the patient wanting?
Patient's Marketing Preference
We DO NOT pass details on to anyone else.
Read our February 2020 article in the Daily Mail
Read our February 2020 article in the Birmingham Post