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Make a referral

Our online referral form is simple, safe, and secure. All patient details will be processed in the strictest confidence. A unique reference number is generated for each enquiry which ensures subsequent communication between Manor Clinic, the referrer and patient, is efficient, accurate and safe. To ensure you successfully receive electronic correspondence from Manor Clinic, please add to your safe list or address book.

All patient details will remain confidential and will only be used for administrative purposes to help us assist with your enquiry. Any information you provide is encrypted and submitted over a secure connection and cannot be viewed by anyone else on the web. Please complete the form below and your enquiry will be dealt with promptly. Alternatively, if your request is of an urgent nature, or you would prefer to speak directly to a member of our dedicated enquiries team, please call: 0800 840 3219

Please complete the following information

Patient details
Please confirm contact details of your patient to allow Life Works to make contact regarding their appointment or treatment options.
GP contact details
Referral details
Risk factors associated with patient
Supplementary patient details
Please click here for our privacy notice

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.

Can't find what you're looking for?
Contact us by phone: 0800 840 3219