Cookies on the Dr Michaels Practice website

We've put some small files called cookies on your device to make our site work.

We would also like to use google translate cookies and analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

You can change your cookie settings at any time using our cookie policy.

Dr Michaels Practice

Home
Language
About Us
Online Services
Our Staff
Latest News
Appointments
Prescriptions
Join the Practice
Opening Hours
Services
Health Information
Practice Policies
Contact Us

Latest News
Appointments
Prescriptions
Join the Practice
Opening Hours
Services
Health Information
Practice Policies
Contact Us

Home
Language
About Us
Online Services
Our Staff

PRIVATE MINOR SURGERY REFERRAL FORM

Please use this form if you are another GP Practice and wish to refer one of your patients to Maypole Health Centre for Minor Surgery. If you have any queries regarding this form, please call 0121 430 2829 and ask to speak to one of the Admin Team.

Last Updated: 03/06/2024

REFERRER DETAILS

Referring GP *

Practice Name *

Practice Address *

Telephone number *

Practice Email address *

Practice Reference Code *

PATIENT DETAILS

Patient Surname *

Patient Forename(s) *

Patient Date of birth *

Patient Address *

Patient Land-Line Number

Patient Mobile Number

Patient Email

Patient NHS Number *

Patient Gender *

Patient Ethnicity *

Diagnosis / Reason for Referral

Reason for referral (CATEGORY) *

Aspirations

Excisions

Incisions

Injections

Any provisional or known diagnosis?

Current Medication: NB any medication which may prolong bleeding?

Other Medical History/Allergies

IS PATIENT PREGNANT? *

Yes No

Site to be injected / of skin lesion/ for aspiration? *

If skin lesion, include size and shape

If skin lesion, is it pigmented?

Yes

Hepatitis or HIV risk? *

Yes No

Oops... There was an error contacting reCAPTCHA, Please try again.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Further Information

Carers Support
Pregnancy Care Planner
GP Earnings
Practice Policies
Feedback & Complaints

Add Footer Link

Accessibility
Cookie policy
Your data
Site map