Self Referral Request Form Use this service to request a referral from a doctor. You can use this service if you are registered at the surgery Who are you completing this form for? Yourself Someone else About YouYour Name First Last Date of BirthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What is your sex? Male Female Other As recorded on your medical recordWhat is your postcode? Postcode Optional The one used to register with your GPPhone NumberEmail Address Named GP (if known): OptionalWhat's on your mindPlease let us know what's on your mind. Have a question for us? Ask away.Who would you like a Referral to? OptionalWhy do you need this Referral? Optional