Private Patient Referral
This private patient referral form is for completion by your general practitioner1 (GP). If this is submitted electronically, a copy will be automatically emailed to your GP2.
This form must only be used for a patient wishing to be seen privately by a specialist within the Oxford Radcliffe Hospitals NHS Trust. These hospitals are the John Radcliffe Hospital, the Churchill Hospital, the Radcliffe Infirmary and the Horton Hospital.
DO NOT use this to refer a patient as an NHS patient
DO NOT use this to refer a patient to be seen in any other private hospital.
DO NOT use this to refer a patient to be seen directly within the Radiology Department. Please refer the patient to one of our Consultant Radiologists.
Would you like to:
| A. Cancel (i.e. return to previous page) | |
| B. Print a blank private referral form to be completed by hand | |
| C. Complete the private referral form online |
Notes:
1 For certain treatments a patient can self-refer without necessarily involving their general practitioner (e.g. for some types of cosmetic surgery). If you would like to self-refer please do not use this form, but instead telephone our Private Referral and Information Service on 0845 40 232 04.
2 To increase confidentiality the copy emailed back to your GP will be encrypted and will require special software to open it.
