BELFAST SLIGO

NI 028 9066 7878

ROI 048 9068 8858

BELFAST SLIGO

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Refer a Patient

CT Referral Form

24Hour/14 Day Loop

Treadmill Referral

X-Ray Referral Form

BP Referral Form

Echo Referral Form

ECG Referral Form

Ultrasound Referral

Please fill in the form below to refer your patient for treatments other than those above.

Referring Clinician Details

Doctor Name *

Practice Address *

Contact Number *

Email

Patient Details

Patient Name *

Patient Address *

Date of Birth *

Contact Number *

Patient Email

Referral Details

Speciality *

Consultant *

Reason for referral *

Funding *

Insured
Self-funding

Funding referral *

If the named consultant is unable to see your patient within our target of 7 working days, would you be happy for us to refer to another appropriate consultant?

Yes
No

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We deal with all consultants and all specialties – we aim to place your patient with an appropriate specialist within 7 working days. Thank you for your referral.

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