NHS Patient Referral

Supporting your patients beyond their prescription

SecuriCare provides a reliable home delivery service for patients using stoma and continence prescription appliances, with ongoing support to help make managing their appliance needs easier.

Simply refer your patient using the form and we'll help get their service set up.

Your details

First name

Last name

Work email address

Work phone number

Job title

Hospital / base

Do you have consent from your patient?

Please ensure you have your patient's permission before proceeding with referral.

Yes

We're unable to proceed with your referral at this time. Please gain consent from your patient.

Patient details

First name

Last name

Address

Postcode

Phone number

Email address

Date of birth

Day

Month

Year

NHS or CHI number

Medical need

Select all applicable conditions from the dropdown.

Date of hospital discharge (if known)

Products required for first order / at discharge

Is SecuriCare CheckIn required?

CheckIn is a free additional support service available for ostomates following discharge. Our trained team will call your patient daily for 7 days after returning home, ensuring they have continued support and escalating any issues to their nurse or GP.

Yes

GP details

GP name

Surgery address

Surgery postcode

Phone number

How we use your information

By submitting this form, you confirm you have the patient’s consent to refer them to our service. CliniMed Ltd will securely process your and your patient’s personal details to provide the requested service, in accordance with UK GDPR and our Privacy Policy.

Stay informed about the latest products

We’d love to keep you updated with relevant products, news and services. Tick this box to hear from SecuriCare (Medical) Ltd and CliniMed Ltd by email, post and phone (where applicable).

We need your permission.

Refer your patient to SecuriCare

Supporting your patients beyond their prescription

Your details

We're unable to proceed with your referral at this time. Please gain consent from your patient.

Patient details

GP details

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Supporting your patients beyond their prescription

Your details

We're unable to proceed with your referral at this time. Please gain consent from your patient.

Patient details

GP details