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Clinic Referral Form
Where are you referring from?
(required)
Please select a value
-- Please Select --
Our Lady’s Hospital, Manorhamilton
Mater University Hospital
St Vincent’s University Hospital
RMDU, Harold’s Cross
University Hospital Waterford
Connolly Hospital, Blanchardstown
Midlands Regional, Tullamore
Tallaght University Hospital
Naas General Hospital
Cork University Hospital
Cappagh Hospital
Patient Details
Patient Name -
(required)
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Patient Phone Number -
(required)
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Type of Arthritis -
(required)
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Your details as the referring health professional
Title
(required)
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Name -
(required)
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Phone Number -
(required)
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Email address -
(required)
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Additional Notes (optional) -
I (as Health Professional) confirm the above patient has given permission to share their information with Arthritis Ireland, so they can access the referral service.
Yes, I have consent
No, I do not have consent
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