Refer your patient to NRAS
Patient details
Title
Please select...
Mr
Miss
Mrs
Ms
Dr
Prof
Mx
First Name
Last Name
Email address
This is an important field. We are able to provide a better service to those with an email address.
Tick if patient doesn't have an email address:
Phone number
Patient's Date of Birth (DD/MM/YYYY)
We use patient Date of Birth to match the patient information to the referral.
Estimated Date of Diagnosis (DD/MM/YYYY)
Please select an approximate value if you cannot remember the exact date, month or year.
Postcode
Address Line 1
Address Line 2
Town or City
County
Country
Please select...
England
Northern Ireland
Scotland
Wales
Your details (as the referring Healthcare professional)
Title
Please select...
Mr
Miss
Mrs
Ms
Dr
Prof
Mx
First Name
Last Name
Email address
Phone number
Role
Please select...
Specialist Nurse/ Nurse Practitioner
Rheumatologist
Physiotherapist
Occupational Therapist (OT)
General Practitioner (GP)
Pharmacist
Social Prescriber
Paediatric Rheumatologist
Paediatric Specialist Nurse
Paediatric Physiotherapist/Play therapist
Podiatrist
Other
Postcode - Organisation
If your organisation isn't listed in the postcode search above, please enter postcode:
XX1 2YY
, and enter the name and address of your organisation in the "Additional Notes" field below
Name of Organisation
Address Line 1
Address Line 2
Town or City
County
Org ID
If you have selected "Organisation Not Listed" above, please add your hospital name and address here:
Practice Type
Please select...
NHS Hospital
Primary Care
Private Hospital
Private Practitioner
Additional notes (optional)
I (as the Health Professional) confirm the above patient has given permission to share their information with NRAS, so they can access the referral service.
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