updoc UK: Form-based asynch consult - Request a Specialist Referral Letter

Request a Specialist Referral Letter
Important Notice:

This referral service is specifically designed for non-emergency situations and is not intended for conditions requiring immediate attention from a doctor. If you are experiencing any of the following, your Partner Practitioner cannot facilitate a referral for you. Instead, it is crucial to contact 111 or visit your local Accident and Emergency (A+E) department. These conditions include but are not limited to chest pain, shortness of breath or difficulty breathing, infections with symptoms like fevers or new rashes, new severe headaches, collapse, loss of consciousness, seizures or fits, slurred speech, loss of power to any muscles or facial droop, heavy bleeding, severe mental health problems including suicidal thoughts, sudden loss of vision, or eye pain. In such cases, immediate medical attention is essential.
Patient Details

Please ensure that you input the details of the person requiring medical advice.
Full name*

First NameLast Name
Sex*

MaleFemalePrefer not to say
Date of birth*

DayMonthYear
Example: 22/03/1990
Email*

Confirmation Emailexample@example.com
Mobile number*
Make sure you double-check you entered the correct number.
NHS number
Leave blank if you don't have one
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consultation Details
Do you have any allergies?*

YesNo
Please specify your allergies.*
Are you currently taking any medication?*

YesNo
Please specify which medication you're taking.*
Do you have any existing medical conditions?*

YesNo
Please specify your existing medical conditions.*
Referral Details
What is the main reason for this referral?*

DiagnosisMedicationInvestigationSecond opinionOngoing careOther
Please provide as much specific information as possible so that your Partner Practitioner can provide an effective solution as quickly as possible to you.*
Your Partner Practitioner will need to know: what your specific issue and symptoms are, your history of allergies, medication, and operations, and any specific medication you think you might need.
Have you tried anything to resolve the problem?*
e.g., pain relief, ankle support
When did your problem, symptoms or condition start?*

DayMonthYear
Is there a specific specialist (person) you'd like to be referred to? Select 'No' if you're uncertain about the specialist's full name, and your Partner Practitioner will recommend someone suitable.*

YesNo
Specialist's Full Name
e.g., Dr John Smith
Specialist's Practice*
Please tell us which type of specialist you would like to be referred to or we can decide this for you after reviewing your problem or medical symptoms.
Specialist's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who should we refer you to?*
Please tell us which type of specialist you would like to be referred to or we can decide this for you after reviewing your problem or medical symptoms.
Do you have a regular UK NHS GP?

YesNo
NHS Surgery
Please provide the name of your NHS GP
NHS Surgery Address
Please provide the address of your NHS GP Surge

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Total

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Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Upon submitting your medical consultation, you acknowledge our Terms and Privacy Policy and consent to the following:
- You are NOT seriously unwell with any of the following symtoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side, slurred speech.
- You have comprehended the questions in the questionnaire and answered them honestly.
- The requested referral letter is solely for the individual with the provided name and details.
- You understand that your Partner Practitioner will arrange a referral to whom they believe is the most appropriate medical specialist or medical speciality based on the clinical information provided.
- You are also aware that the specialist you am referred to may advise a further onward referral to someone else more specialised with your condition or problem.
- updoc is not a replacement for a doctor's visit, nor is updoc your primary doctor or GP, and your Partner Practitioner may be unable to access your NHS or regular GP medical records.
- If your symptoms persist or you have not fully recovered, you agree to consult with your regular doctor or GP for further medical advice
Do you agree to the above Terms?*

Yes
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Request a Specialist Referral Letter

Important Notice:

Patient Details

Consultation Details

Referral Details