Accelerate the Progress of an Existing Hospital Referral

This form is NOT intended to be used as a tool to find out where you are on the waiting list. Only the hospital you have been referred to will have access to that information.

Please do not use this form for radiology referrals or appointments.

Please be advised that you should contact the hospital to which you have been referred to discuss the progress of your referral prior to using this form.

This form is intended for use by patients who have been asked by the hospital / consultant to which they have been referred , to contact their GP to enable their referral to be accelerated.

Patient name *

Please type your full name (as it is written on our practice records).

Date of birth *

Patient email address *

Please include your email address so we can reply to you.

Have you called the hospital? *Yes Yes & they have advised an expediteNo

If you haven’t called the hospital, please do so before completing this form. Thank you.

Details of discussion with hospital

Name of hospital you have been referred to? *

Name of department you have been referred to? *

First appointment or follow up? *First appointmentFollow up appointment

Consultant name if known?

New / deteriorating symptoms? *

Impact on daily life / activities? *

Submit