Online Referral Form

If you are registered with a Newcastle GP and would like to refer yourself, please complete the online form below or telephone or email using the following contact information.
Tel: 0191 2826600 Email: (Please be advised that email contact cannot be guaranteed as secure)
We will contact you by your preferred method within 3 working days. If you do not hear from us within this time frame please call us on 0191 2826600.
Please note, fields marked with an asterisk * must be completed.
This online referral form is fully secure and all details below will be stored on our secure and confidential system. Please note, by completing this form you agree to these terms.

Your Information

Contact Details

If we are unable to contact you by phone or leave a message we will write to you.

GP Details

Referral Information

Please give us a brief description of why you would like to be seen in our service.

Other Information

Please note, a telephone translator and interpreter service is available – please indicate below if this is required and the language you would prefer to use. We will then arrange for an interpreter to be available when we contact you.

Use of Information

Thank you for completing this form. Before pressing the submit button below, please ensure you have entered all the relevant characters into the white box in the captcha (please note they are case sensitive and there are often two words required separated by a space). Once you press the submit button, please wait until you receive the green success message. If you do not see this, please review your form as it may require amendments or there may be an incomplete mandatory field.
Thank you for contacting our service, we will be in touch soon.