Make a Referral

Our online referral form is secure, confidential, and easy to use. All patient information is handled with the highest level of privacy and security. Upon submission, a unique reference number is generated, ensuring efficient, accurate, and secure communication between Bramacare, the referrer, and the patient.

Please complete the following information

Patient details

Patient name *(Required)

Gender

Date of birth

Patient address

Address Line 1 Address Line 2 City ZIP / Postal Code

Telephone number *(Required)

Email address

Terms for Parent Details

Please confirm contact details of your patient to allow Bramacare to make contact regarding their appointment or treatment options.

Referee contact details

Name of Clinician *

Address *(Required)

Address Line 1 Address Line 2 City ZIP / Postal Code

Telephone number *(Required)

Email address

Diagnosis or condition if known *(Required)

Risk factors associated with patient

Supplementary patient details

Clinical Information

(Please note weight, height, and BMI are mandatory fields. The referral cannot be processed without this information.)

Weight:(Required)

Height:(Required)

BMI:(Required)

Weight change in the last three months:

Month 1:

Month 2:

Month 3:

Medication

Investigations

Additional supporting information e.g. physical health issues

Recent consultations

Click here for full privacy notice(Required)

By clicking send you agree to us using the information provided to manage your enquiry. If enquiring on behalf of someone else, you must obtain their consent to providing us with their information.

Make a referral

Patient details

Referee contact details

Clinical Information

Weight change in the last three months:

Individual

Referrers

Business

Contact