Make a Referral to St Mary's Hospital

Please fill out this form accurately. It will enable us to give a faster, more specific response

Patient and Your Details

Patient Details

Patient Name
Date of Birth
Current Hospital No
GP Name & Address

Which Hospital is the patient in

Ward

Your Details

Current Consultant

Speciality

Referring Dr's Name

Grade

Bleep No
Email Address*(must be NHS)

Patient History and Examination

History and Examination

Medication
Allergies

Previous Independence

Check if Patient is on

GCS

Eyes

Voice

Motor

Left Pupil Size / mm

Right Pupil Size / mm

For Spinal Referrals

If Malignancy - primary location
Life Expectancy

Submit

What is your working Diagnosis

and specific question