Brinkmann Gynaecology

GP Referral Form

At which clinic would you like your patient to be seen? *indicates compulsory fields

Referral Urgency*

Patient Details

Patient’s First Name*

Patient’s Last Name*

Patient’s Date of Birth*

Patient’s Phone Number*

Patient’s Mobile Number

Patient’s referral letter/relevant medical history notes, or

Clinician’s details

Referring clinician*

Email address*

Practice name*

Practice Telephone Number*

Practice Fax Number

Practice Address

Gynaecology referral

Oncology referral