Private Referrals

Thank you for this private referral and for choosing me to be a part of your patient’s care team. After submitting this referral, you will receive a confirmation email with a copy of the completed form sent directly to your inbox.

If you have any additional questions, please feel free to contact us.

Referrer's Email

Confirm Email

Would you like confirmation from our team that your referral was received and that we have contacted your patient? Please ensure an email address is provided above if you would like this follow-up.

Name of Your Surgery or Clinic

Phone Number of Your Surgery or Clinic

Patient's Name

First

Last

Patient's Email

Confirm Email

or Name regarding

Patient's Phone Number

Reason for Referral

Stress
Health Anxiety
Palpitations (any cause)
Other (specify below)

Please include any additional details regarding this referral.

Consent to Contact Patient

I confirm that I have informed the patient about this private referral to DoubleCheq.

DoubleCheq is committed to protecting and respecting your privacy. We will only use your personal information to administer your account and to provide the products and services you request from us. We do not use information collected in this form for general marketing purposes and your data will not be shared with third parties without your consent.

Dr Richard Williams

Private Referrals