Clinician Referral – KURClinic

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Referrers
Pathways
Programme
Treatment
Our Approach
Questionnaire
About

Clinician Referral

Refer a patient to KUR Clinic.

Please complete the following to refer a patient to KUR Clinic. All information is held securely and in strict confidence.

Step 1 of 4 — About You

About you.

Please provide your details as the referring clinician.

Your name *

Specialty

Practice or hospital

Email address *

Phone number *

Step 2 of 4 — About the Patient

About the patient.

Please share as much clinical detail as you can. This allows us to assess the referral thoroughly before we are in touch.

Patient first name *

Patient last name *

Date of birth

Presenting complaint

Relevant medical history

Current medications

Step 3 of 4 — Referral Details

Referral details.

Please indicate which pathway you feel may be most appropriate, and any other details relevant to this referral.

Which pathway do you feel is most appropriate? *Select all that apply.Chronic PainComplex Musculoskeletal ConditionsPsychosomatic DisordersAutonomic Nervous System DysregulationUnsure — I would welcome a clinical discussion

How urgent is this referral? *RoutineSoon — within the next 4 weeksUrgent — within the next week

Do you have a referral letter?Yes, I will attach oneNo, but I can provide oneNo, this form is sufficient

Attach referral letter (optional)

No file chosen

Any additional notes or requests

Step 4 of 4 — Consent

Consent confirmation.

Before submitting, please confirm the following.

I confirm that the patient named above has consented to this referral and to their information being shared with KUR Clinic for the purpose of clinical assessment. I understand this information will be held securely and will not be shared with third parties without consent.

Referral summary

Patient: {name-2-first-name} {name-2-last-name}
Pathway: {checkbox-1}
Urgency: {checkbox-2}
Referral letter: {radio-2}, File: {upload-1}

Consultant-led integrated care for complex and chronic conditions

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For Referrers
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The Programme
Treatment
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About KUR

For Referrers
The Pathways
The Programme
Treatment
Our Approach
Questionnaire
About KUR

Contact

hello@kurclinic.com
86 Harley Street, 4th Floor
London W1G 7HP
Mon-Fri: 8:30am-8pm
Saturday: 9am-1pm