Referral forms for GPs and other Medical Practitioners

Referral forms for GPs and other Medical Practitioners

To make a referral, complete the form below as completely as possible. Details will be stored on our server which only we can access, meaning it is not transmitted by e-mail. This will help to preserve patient confidentiality.

You may also fax/send an accompanying letter/ print out if you wish to do so. Any supplementary information should be included in this letter. Alternatively this form can be downloaded here, and then printed off and sent to us or faxed. It is important to try and include all reports of relevant scans as requested, and we will need to see the original scans prior to consideration of any treatment. The patient may bring them with them to their appointment. Cambridge Urology Partnership will contact the patient and make an appointment.

Fields marked with * are mandatory

GP name*:
GP Practice:
GP telephone*:
GP email address*:
Referral urgency:
 Urgent/Emergency Routine
Patient's name*:
Patient's date of birth*:
Patient's address*:
Patient's home telephone number:
Patient's mobile telephone number*:
Patient's email address*:
Referral letter:
Security Code*: captcha
Verify your submission by entering the security code: