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Clinician Referral

To make a patient referral to one of our consultants please complete the secure online form.


  • If the patient has private medical insurance, Please choose from the drop down, if not please select Self Funding
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Independent Practice Services is fully committed to compliance with Data Protection and Department of Health medical confidentiality guidelines. The personal information that you submit using this form will be held securely by us and your personal information will not be shared with anyone outside of Independent Practice Services, or used for any other purpose than to respond to your enquiry and/or request.