Sport and Exercise Medicine Service Referral

Make a Referral to the Sport and Exercise Medicine Service at the White House Clinic.

Patient Name:

Patient email address:

Patient Phone number:

Patient DOB:

Consultant Name:

Consultant Email Address:

Body Part:

Consultation Options:

If applicable, Injection Information Leaflet given (see below)

Further Notes:

Document upload:

If you have any supporting documentation, please upload it here.

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

The referrer and the patient will receive a confirmation email.

By completing this form, the referring party confirms the details are accurate and that the appropriate documentation has been provided to the client.

Thanks for your submission!

Oops! Something went wrong while submitting the form.

Important Points to Note

Injection Information Leaflet
If the client has been referred for an injection, please ensure that the Injection Information Leaflet is provided. Please scan the QR code below or click here.
If client is not suitable for the procedure
If the client attends for an injection and is deemed unsuitable for the procedure, they will only be charged for the consultation.
Other Services Offered by SEM
- Referrals for consideration of further Imaging and blood tests
- Advanced Ultrasound Guided Procedures (Hydro dilatation, High Volume Injection, Barbotage)
– More info can be found here.
Note
Clients will need to be assessed at an initial Consultation Assessment for suitability for these advanced procedures.