Thank you for this private referral and for choosing DoubleCheq to be a part of your patient’s care team.  After submitting this referral for self-care support, 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 via email at [email protected].

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referral. Number Consent

Referrer's Email *

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. *

• Yes
• No

Name of Your Surgery or Clinic *

Phone Number of Your Surgery or Clinic

Patient's Name *

First

Last

Patient's Email *

Email

Confirm Email

Patient's Phone Number

Reason for Referral *

• Acid Reflux
• Atrial Fibrillation
• Cardiovascular Disease Prevention
• Health Anxiety
• Heart Palpitations
• Herniated Disc
• Inguinal Hernia
• Menopause
• Stress
• 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.

GDPR Agreement *

• I consent to having this website store my submitted information.

SEND REFERRAL

DoubleCheq is committed to protecting and respecting your privacy, and 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 contact form for general marketing purposes.