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Call us on 020 7188 5197

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Guy's and St Thomas'

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Home | Patient referral form

Patient referral form

Refer a patient by using our online referral form or alternatively contact our reservations team on

020 7188 5197 or by email: PrivatePatientEnquiries@gstt.nhs.uk.

Step 1 of 3 - Patient details

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Name*
Title* First name* Last name*
Address*
Address Address line 2 City County / state / region Postcode Country
Gender*
- Male
- Female
Date of birth*
Is the patient*
- Insured
- Self Pay
Medical insurer*
Membership no*
Telephone*
Email address*

Referrer details
Full name*
First name* Last name*
Practice name*
Practice address*
Practice address Address line 2 City County / state / region Postcode Country
Telephone*
Email address*

Referral details
Speciality*
Reason for referral*
Preferred consultant(s) (if known)
Preferred date for appointment*
- Urgent
- One week’s time
- Within one month
- Other
Please specify
By ticking this box you give your consent as the referrer and the patient being referred consent to be contacted by Guy’s and St Thomas’ Private Healthcare via the details supplied.*
- I agree
Declaration by referrer
Declaration by referrer*
- The information I have provided on this form is correct to the best of my knowledge.
The patient consents to be contact via the details supplied.
- Yes
- No

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Make an enquiry

Enquiry Type
First name*
Last name*
Who is the enquiry for?*
Date of birth
DD slash MM slash YYYY
Patient details
Patient's first name*
Patient's last name*
Service required
Email*
Telephone*
First line of address*
Postcode*
Country*
GP details
GP name
Practice name
First line of practice address*
Appointment details
Preferred consultant
Speciality
Payment choice
Message
How did you first hear about our private patient services?
GDPR Consent*
This form collects your information to enable us to deal with your enquiry. Read our privacy policy for more information about how we manage your data.
- I consent to having Guys' and St Thomas' Private Healthcare collect my information.

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Part of Guy's and St Thomas' NHS Foundation Trust

Guy’s Hospital, Great Maze Pond, London SE1 9RT

St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH