Referral Forms

Lower Gastrointestinal Referral Form

Please print a copy of the Lower Gastrointestinal Endoscopy Referral Form, complete all the details and sign the form. Completed forms should be faxed to the relevant treatment centre.

If you are referring a patient to Emersons Green NHS Treatment Centre, Devizes or Shepton Mallet NHS Treatment Centres, to download a Microsoft Word version of the Lower Gastrointestinal Endoscopy Referral Form please follow this link . A pdf copy of the form for these centres is also available here.

Gastroscopy Referral Form

To refer a patient for gastroscopy, please download the relevant referral form depending on which treatment centre you are referring to, fill it out in full and return via fax to the number indicated on the form.

If you are referring a patient to Emersons Green NHS Treatment Centre or Devizes NHS Treatment Centre, to download a Microsoft Word version of the Gastroscopy Referral Form please follow this link . A pdf copy of the form for these centres is also available here.

If you are referring a patient to Shepton Mallet NHS Treatment Centre, to download a Microsoft Word version of the Gastroscopy Referral Form please follow this link. A pdf copy of the form for Shepton Mallet NHS Treatment Centre is also available here.

Imaging Request Form

Please print a copy of the imaging request form, complete all the details and sign the form. Completed forms should be faxed to the relevant treatment centre.

If you are referring a patient to Devizes or Emersons Green NHS Treatment Centre , to download a Microsoft Word version of the Imaging Request Form please follow this link. A pdf copy of the form for these centres is also available here. For further information about this service please call 0117 906 1861 or e-mail uksh-radiology@nhs.net.

GPs can refer NHS patients to Shepton Mallet NHS Treatment Centre for direct access ultrasound and x-ray services. To refer a patient to Shepton Mallet NHS Treatment Centre using the Imaging Request Form, please follow this link. For further information about these services please call 01749 333 621 / 622 or e-mail smtc-radiology@nhs.net.

Referrals to Shepton Mallet NHS Treatment Centre for MRI scans are available but must be made through OASIS (Orthopaedic Assessment Service in Somerset).

Dental Surgery Referral Form

Please print a copy of the oral surgery referral form, complete all the details and sign the form. Completed forms should be faxed to the relevant treatment centre.

To download a Microsoft Word version of the form for Cirencester, Devizes and Emersons Green NHS Treatment Centres, please follow this link. A pdf copy of the form for these centres is also available here.

To download a Microsoft Word version of the form for Shepton Mallet NHS Treatment Centre please follow this link. A pdf copy of the form for Shepton Mallet NHS Treatment is also available here.

Urology Referral Form

UKSH offers a comprehensive urology one stop consultation clinic for non-visible (microscopic) haematuria and UTI at Emersons Green NHS Treatment Centre. This is a consultant led and provided service. Our microscopic haematuria service is designed to specifically address the anxieties concerning this finding as promptly and conveniently for the patient and referring GP as possible.

Please note that this service is not for any suspected cancer cases, which should be referred to your local general hospital under the Two Week Wait rule.

Please print a copy of the Urology Referral Form, complete all the details and sign the form. Completed forms should be faxed to Emersons Green NHS Treatment Centre. To download a Microsoft Word version of the form please follow this link. A pdf copy of the form is also available here.