Practitioner Referral

Refer a patient to The TMD Physio. Complete the form below and attach any relevant reports, scans or referral letters.

Referrer Details

Your Name *

Practice / Clinic Name *

Your Email *

Your Phone *

Patient Details

Patient Full Name *

Patient Date of Birth *

Patient Email

Patient Phone

Patient Address

Address Line 1 *

City / Town *

Postcode *

GP Details (optional)

GP Name

GP Surgery

Clinical Details

Primary Suspected Condition *

Urgency *

Preferred Appointment Timeframe

Reason for Referral *

Relevant Medical History *Or tick here if details are in the attached MH form

Current Medications *Or tick here if details are in the attached MH form

Payment Method

How will the patient pay? *

Note: We do not accept Bupa, AXA PPP, Aviva or Vitality. Self-pay options available.

Supporting Documents

Click to attach MRI scans, reports, MH forms or letters

PDF, JPG, PNG, DOC, DOCX or HEIC — up to 5 files, 15MB each

Patient Consent

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