Referral forms

Referral forms are available to download for services at The Royal London, Mile End and St Bartholomew’s hospitals.

Two week cancer referral forms are available separately here.

Paper Switch Off and GP referrals

Barts Health implemented paper switch off in October 2018. Please visit the referrals page for further information.
Referral form in Word Referral form in EWDT
Cancer  

Cancer single point of referral checklist 2MB

Cancer consultant upgrade request form (Barts Health staff referrals only) 73KB

  
Cardiology  
Rapid Access Chest Pain Clinic Referral Form Newham Hospital ewdt not available
Rapid Access Chest Pain Clinic Referral Form Whipps Cross Hospital  
Rapid Access Chest Pain Clinic Referral Form St Barts / Royal London Hospital  
Rapid Access Heart Rhythm clinic referral form 46KB ewdt not available
Cardio-respiratory rehab referral form 124KB ewdt not available
TAVI inpatient referral form [docx] 319KB  
Dental and OMFS  

For all referral forms visit our dental website

  
Dermatology  
Dermatology Inpatient Referral Form - Whipps Cross Hospital  
Digestive disease  
Gastroscopy referral form 117KB  
Gastrocopy referral form (Whipps Cross only)  
Flexible sigmoidoscopy referral form 107KB  
Hepatobiliary and Pancreas Surgery  

HPB severe acute pancreatitis referral form 373KB

  
Hepatobiliary and Pancreas Cancer referral form 455KB  
Imaging  
Imaging request form 148KB - RLH/NH/SBH ewdt not available
Imaging request form 113KB - Whipps Cross Hospital   
Dexa scan referral form 100KB ewdt not available
Maternity  
Maternity endocrine referral form 57KB  
Maternity ultrasound referral form 49KB  
Antenatal care referral form 90KB  
Clinical outcome form from the antenatal clinic[pdf] 646KB  
Musculoskeletal  
Musculoskeletal referral form 2MB ewdt not available
Neurophysiology   
Neurophysiology request form RLH 37KB  
Palliative care  
PallE8 referral form 392KB  
Paediatrics  

Complications of excess weight referral form (paediatrics) [docx] 31KB

This is targeted support for a small number of young people with severe complications due to excess weight who are engaged and ready to make holistic lifestyle change.

  
Respiratory medicine  
Anaesthetic allergy referrals.doc [doc] 2MB  
General allergy referrals.doc [doc] 47KB  
Tower Hamlets Community Health Service  
Tower Hamlets Children’s Services Referral Form (SPA form)   
Tower Hamlets Children’s Services Referral Guidance  
Tower Hamlets Autism Spectrum Disorder Assessment Service (ASDAS) Referral Form  
Tower Hamlets ASD Assessment Referral Guidance