Referral form Personal information Note: Questions marked by * are mandatory *This is a mandatory field. Date of birth *This is a mandatory field. First name *This is a mandatory field. Last name *This is a mandatory field. Gender *This is a mandatory field. Previous GP/NHS number *This is a mandatory field. Port reference *This is a mandatory field. Mobile number *This is a mandatory field. Hotel/homeless *This is a mandatory field. Room number *This is a mandatory field. Country of origin *This is a mandatory field. Preferred language *This is a mandatory field. Date entered the UK *This is a mandatory field. Number of family members *This is a mandatory field. Current health concerns *This is a mandatory field. Is the client pregnant How many weeks/months *This is a mandatory field. Does the client consent to register at this GP and to this referral being done? Please Select An Option YesNo *This is a mandatory field. Are you happy for us to share your full medical records electronically with other services involved in your care? Please Select An Option YesNo *This is a mandatory field. Patient initials *This is a mandatory field. Patient to print their name referral completed by patients (themselves) *This is a mandatory field. Staff to print their name if helping patient *This is a mandatory field. Do you confirm that by completing this form, you agree to be registered at the Rainbow health centre and understand that it will be your GP? Yes No
