MIDLOTHIAN HEALTH CARE CO-OPERATIVE

							                      MIDLOTHIAN HEALTH CARE CO-OPERATIVE
                            MINOR SURGERY SERVICE
                                  PENICUIK MEDICAL PRACTICE
                                        37 IMRIE PLACE
                                            PENICUIK
                                            EH26 8LF

                                         REFERRAL FORM
                   To make an appointment please fax, post or email this form to:


      Dr Hamish Reid/Dr A Drummond Begg, Penicuik Medical Practice. Fax 01968 671 543, or/
                             email - rachel.hall@lothian.scot.nhs.uk



Patient Details:                                   GP Details:
        Name:                                             Name:
     Address:                                            Address:

    Postcode:                                            Postcode:
        DoB:                                         Practice Code:
                                                           Fax No:
     CHI no:
                                                     Telephone No:
Telephone no:                                      Date Of Referral:

REASON FOR REFERRAL




Current Medication/Medical Conditions:




On Warfarin: YES     NO                            On Asprin: YES      NO
Allergies:

REFERRING PRACTICE; AFTER FAXING OR POSTING PLEASE RETAIN THIS FORM IN
PATIENT’S RECORDS