{"id":8470,"date":"2020-10-17T16:59:43","date_gmt":"2020-10-17T15:59:55","guid":{"rendered":"https:\/\/www.albanyhousesurgery.nhs.uk\/?page_id=8470"},"modified":"2020-10-18T11:15:22","modified_gmt":"2020-10-18T10:15:22","slug":"private-referral-for-appointment-or-scan","status":"publish","type":"page","link":"https:\/\/www.albanyhousesurgery.nhs.uk\/you-your-health\/who-do-i-see\/private-referral-for-appointment-or-scan\/","title":{"rendered":"Private referral for appointment or scan"},"content":{"rendered":"\n<p>Please help us by giving us as much information as possible. This form is not for urgent referrals. If you have not heard from the surgery after 5 days or are unsure if the form has been sent then please contact us on 01905 26086.<\/p>\n\n\n<link rel='stylesheet' id='formidable-css' href='https:\/\/www.albanyhousesurgery.nhs.uk\/wp-content\/plugins\/formidable\/css\/formidableforms.css?ver=4271550' media='all' \/>\n<div class=\"frm_forms  with_frm_style frm_style_big_text\" id=\"frm_form_24_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_hnlsj6310\"  >\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">Referral Request<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"24\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_24\" id=\"frm_hide_fields_24\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"hnlsj6310\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_24\" name=\"frm_submit_entry_24\" value=\"33a28479a4\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/8470\" \/><div id=\"frm_field_529_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_xu1tj6310\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xu1tj6310\" name=\"item_meta[529]\" value=\"\"  data-reqmsg=\"First Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_530_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_xt7az6310\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xt7az6310\" name=\"item_meta[530]\" value=\"\"  data-reqmsg=\"Last Name cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_531_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ppbxb6310\" class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_ppbxb6310\" name=\"item_meta[531]\" value=\"\"  data-reqmsg=\"Email cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_ppbxb6310\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_ppbxb6310\">Enter Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_conf_531_container\" class=\"frm_form_field frm_none_container frm_conf_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_conf_ppbxb6310\" class=\"frm_conf_label frm_primary_label\">Confirm Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_conf_ppbxb6310\" name=\"item_meta[conf_531]\" value=\"\"  placeholder=\"Please confirm your email\" data-reqmsg=\"Confirm Email cannot be blank.\" aria-required=\"true\" data-confmsg=\"The entered values do not match\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_conf_ppbxb6310\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_conf_ppbxb6310\">Confirm Email<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_532_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_w1eya6310\" class=\"frm_primary_label\">Date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_w1eya6310\" name=\"item_meta[532]\" value=\"\"  data-frmmask=\"99\/99\/9999\" placeholder=\"DD\/MM\/YYYY\" data-reqmsg=\"Date of birth cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\" pattern=\"\\d\\d\\\/\\d\\d\\\/\\d\\d\\d\\d$\"   aria-describedby=\"frm_desc_field_w1eya6310\"\/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_w1eya6310\">Please use format day\/month\/year e.g. 12\/05\/1979<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_533_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_spq8l4310\" class=\"frm_primary_label\">Phone Number\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_spq8l4310\" name=\"item_meta[533]\" value=\"\"  data-reqmsg=\"Phone Number cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_534_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ytves\" class=\"frm_primary_label\">Your Named GP &#8211; if known\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ytves\" name=\"item_meta[534]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1369_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_285uo\" class=\"frm_primary_label\">If you are requesting a private referral please give full details of the specialist&#8217;s name and location.\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_285uo\" name=\"item_meta[1369]\" value=\"\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_536_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_ck0vj\" class=\"frm_primary_label\">**Important** Please provide us with a good summary of your condition as well as the reason for your referral. This will be sent as part of your referral letter and will help the specialist better understand your case.\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[536]\" id=\"field_ck0vj\" rows=\"5\"  data-reqmsg=\"**Important** Please provide us with a good summary of your condition as well as the reason for your referral. This will be sent as part of your referral letter and will help the specialist better understand your case. cannot be blank.\" aria-required=\"true\" data-invmsg=\"**Important** Please provide us with a good summary of your condition as well as the reason for your referral. This will be sent as part of your referral letter and will help the specialist better understand your case. is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_537_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_xzyfw3\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_537-0\"><label for=\"field_xzyfw3-0\"><input type=\"checkbox\" name=\"item_meta[537][]\" id=\"field_xzyfw3-0\" value=\"I confirm that my enquiry is not urgent, and understand it may take up to 5 working days before I receive a reply.\"  data-reqmsg=\"We need your confirmation to proceed. Please tick the box to confirm.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I confirm that my enquiry is not urgent, and understand it may take up to 5 working days before I receive a reply.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_538_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Privacy Policy<\/h3>\r\n\r\n\r\n<div id=\"frm_field_539_container\" class=\"frm_form_field  frm_html_container form-field\">This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our <a href=\"https:\/\/www.albanyhousesurgery.nhs.uk\/about-us\/practice-policies\/patient-record\/how-we-use-your-data\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a> to discover how we protect and manage your submitted data.<\/div>\n<div id=\"frm_field_540_container\" class=\"frm_form_field form-field  frm_required_field frm_inline_container vertical_radio\">\r\n    <label for=\"field_kou3a\" class=\"frm_primary_label\"> \r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_540-538-0\"><label for=\"field_kou3a-0\"><input type=\"checkbox\" name=\"item_meta[540][]\" id=\"field_kou3a-0\" value=\"I consent to the practice collecting and storing my data from this form.\"  data-sectionid=\"538\" data-reqmsg=\"We need your consent to proceed. Please tick the box to consent.\" data-invmsg=\"  is invalid\" aria-invalid=\"false\"   aria-required=\"true\"  \/> I consent to the practice collecting and storing my data from this form.<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t<input name=\"frm_state\" type=\"hidden\" value=\"uD6GEJNAc9DZltuyRGyX5v7D2HgvCOK3Hl5QHOhlR7U=\" \/><div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Send<\/button>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n<\/form>\n<\/div>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Please help us by giving us as much information as possible. This form is not for urgent referrals. If you have not heard from the surgery after 5 days or are unsure if the form has been sent then please contact us on 01905 26086.<\/p>\n","protected":false},"author":6577923,"featured_media":0,"parent":5037,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_coblocks_attr":"","_coblocks_dimensions":"","_coblocks_responsive_height":"","_coblocks_accordion_ie_support":"","_uag_custom_page_level_css":"","footnotes":"","_links_to":"","_links_to_target":""},"categories":[],"tags":[],"acf":[],"uagb_featured_image_src":{"full":false,"thumbnail":false,"medium":false,"medium_large":false,"large":false,"1536x1536":false,"2048x2048":false,"mailpoet_newsletter_max":false},"uagb_author_info":{"display_name":"roy-hamilton","author_link":"https:\/\/www.albanyhousesurgery.nhs.uk\/author\/roy-hamilton\/"},"uagb_comment_info":0,"uagb_excerpt":"Please help us by giving us as much information as possible. This form is not for urgent referrals. If you have not heard from the surgery after 5 days or are unsure if the form has been sent then please contact us on 01905 26086.","publishpress_future_action":{"enabled":false,"date":"2024-05-15 07:18:15","action":"change-status","newStatus":"draft","terms":[],"taxonomy":"category"},"_links":{"self":[{"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/pages\/8470"}],"collection":[{"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/users\/6577923"}],"replies":[{"embeddable":true,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/comments?post=8470"}],"version-history":[{"count":4,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/pages\/8470\/revisions"}],"predecessor-version":[{"id":8630,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/pages\/8470\/revisions\/8630"}],"up":[{"embeddable":true,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/pages\/5037"}],"wp:attachment":[{"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/media?parent=8470"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/categories?post=8470"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.albanyhousesurgery.nhs.uk\/wp-json\/wp\/v2\/tags?post=8470"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}