Locations

Speciality required*
Other speciality (please specify)*
Current symptons*
Describe any symptoms your child is experiencing
Reason for request and previous history*
Clinical documentation
Please attach any referral letters, images or other relevant documents
Max. file size: 128 MB.
Plastic surgery requests - Photographic evidence*
Please upload a photo of the affected area
Max. file size: 128 MB.

Preferred consultation format
Tell us how you would prefer the first consultation to take place
Preferred consultant (if known)
Preferred consultation days
Select all that apply
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
Preferred consultation times
- Morning
- Afternoon
- Evening
Funding type*
Insurer name*
Membership number
Pre-authorisation number
How did you first hear about our private paediatric services?*
Other*
Consent*
This form collects your information to enable us to deal with your enquiry. Read our privacy policy for more information about how we manage your data.
I agree to the privacy policy and to having Guys' and St Thomas' Specialist Care collect my information.

Parent/ Guardian name*
Title First Last
Email*
Telephone*
Message*
How did you first hear about our private children's services?*
Other*
Consent*
This form collects your information to enable us to deal with your enquiry. Read our privacy policy for more information about how we manage your data.
I agree to the privacy policy and to having Guys' and St Thomas' Specialist Care collect my information.

Speciality required
Preferred consultant
Payment details
Please provide details
Message*
How did you hear about our private patient services?*
Other*
Consent*
This form collects your information to enable us to deal with your enquiry. Read our privacy policy for more information about how we manage your data.
I agree to the privacy policy and to having Guys' and St Thomas' Specialist Care collect my information.
Referrer declaration*
The correct patient details have been provided. I have discussed the examination, including any intervention with the patient / guardian. I have given sufficient clinical information for the request to be justified and consent for Guy's and St Thomas' Specialist Care to collect mine and the patient's information.
I have read and agree to the below declaration.