Patient Activated Referral

1. About this self-referral form

This survey has been designed to ensure we can give you with the most appropriate treatment and support.

You must complete all questions marked with * to provide the information we need to ensure that you are seen in the right service and by the right clinician.

It takes approximately 15 minutes on average to complete this form. 

Your NHS Number

Before you start, please ensure that you have your NHS Number at hand. Please note that we will not be able to process your referral without it

You should be able to find your NHS Number on any letter or document you have received from the NHS, including prescriptions, test results, and hospital referral or appointment letters. If you cannot find your NHS Number at home, you can ask your GP practice to help you. They should be able to provide the number for you as long as you are registered with them.  

Everyone registered with the NHS in England, Wales and the Isle of Man has a unique patient identifier called an NHS Number. Your NHS Number helps healthcare staff and service providers identify you correctly and match your details to your health records. This will ensure you receive safe and efficient care within the NHS. Each NHS Number is made up of 10 digits shown is a 3-3-4 format (e.g. 000-000-0000). When prompted please enter the 10 digits only, with no spaces or dashes.

Confirmation email

Once you have submitted your self-referral, a confirmation email will be sent to the email address you have provided. If you have not received a confirmation email, please check your Junk E-Mail folder.