Sexual Health Service - GP Referral Form

Patient Details

Name: *

Date of Birth *

Address *

Contact phone number *

Preferred contact details *

Date of referral *

Consent to contact *

Yes No

Patients registered GP and name of practice *

GP Name *

Name of referrer if not registered GP *

Reason for referral *

Significant Medical History /Contraceptive history *

Allergies *

Current Medication *

Relevant investigations and their results *

Where does the patient prefer to be seen? *

Blandford Bournemouth Bridport Portland Weymouth

Please note, the patient will be booked a telephone triage appointment in the first instance and if the patient needs to be seen, they will be booked a further appointment in one of our clinics.

Sexual Health Dorset