Doctor Referral Form

Doctor referral form

Submit referral information for review by the practice. Do not use this form for emergency referrals.

Doctor referral form

Use this placeholder for non-emergency referral administration only. Do not use it for emergency referrals or rely on it for secure clinical submission until a practice-approved encrypted backend is connected.

Prototype placeholder only. Do not collect or rely on patient information through this form until it is connected to a secure, encrypted, practice-approved submission service.

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Referring doctor details
Patient details
Referral details
Uploads
Consent

Leave this field blank

Referring doctor detailsSection 1 of 5

Referring doctor full name*

Practice/facility name*

HPCSA number*

Email address*

Phone number*

Preferred contact method*

Patient detailsSection 2 of 5

Patient first name*

Patient surname*

Date of birth*

Parent/guardian name*

Parent/guardian contact number*

Parent/guardian email

Referral detailsSection 3 of 5

Reason for referral*

Clinical summary*

Duration of symptoms

Relevant examination findings

Current medication

Allergies

Previous investigations

Referral urgency*

UploadsSection 4 of 5

Referral letterUpload only if available and appropriate for this placeholder workflow. Accepted file types: .pdf, .jpg, .jpeg, .png, .doc, .docx. Maximum size: 10 MB per file.

Medical reportsUse separate files for reports where possible. Accepted file types: .pdf, .jpg, .jpeg, .png, .doc, .docx. Maximum size: 10 MB per file.

Test resultsInclude EEG, imaging or blood results only if requested by the practice process. Accepted file types: .pdf, .jpg, .jpeg, .png, .doc, .docx. Maximum size: 10 MB per file.

ConsentSection 5 of 5

I confirm I am authorised to submit this referral information.

I acknowledge that patient information must be handled according to privacy and POPIA-aware practice processes.

This website provides general information and is not for emergencies. If your child is acutely unwell, has a prolonged seizure, breathing difficulty, reduced responsiveness, or any medical emergency, please go to the nearest emergency department immediately.

This placeholder clears entered values after validation. Read the Privacy Policy and Medical Disclaimer before submitting.