COVID treatment Referral form

  • Please do not complete this form if you are NOT SEVERELY HIGH RISK (CLINICALLY SHIELDING). You will know if you are in this category as you will have received a letter or correspondence from us or a hospital specialist last year. If you've never been advised that you are COVID high risk then DO NOT fill this form and request a call with the doctor to discuss first.

  • Please DO NOT complete this form if you do NOT have a POSITIVE PCR test

  • Even if we refer you based on incorrect information you supply us, you will not get the treatment as the hospital unit will decline the referral. Please do not fill out the form dishonestly as you will be WASTING NHS TIME

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Patient's Details
will be needed to enable communication, PLEASE NOTE THIS DOWN
COVID treatment eligibility

Please do not continue with filling out the form if you do not have any symptoms or you do not have a positive PCR test. If you are waiting for the test result, you cannot be considered for treatment until you have a positive PCR test so please wait for the result before requesting COVID treatment therapy.

Proof of PCR test upload

Proof of COVID-19 positive PCR test

Please upload proof of your positive PCR test

Please either take a screenshot of the result or take a picture of the result. PLEASE ENSURE IT SHOWS YOUR NAME AND DATE OF BIRTH SO WE CAN ENSURE THE TEST RESULT IS CONNECT TO YOU

Only following file extensions are allowed: jpg, jpeg, png, webp, pdf, doc, docx, pptx

Once you submit the form, a member of staff will send a referral to the COVID-19 Medicines Delivery Unit (CMDU). They will contact you directly, we will not be able to provide you with details or updates with regard to that.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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