Health Professional Referrals - Charcot-Marie-Tooth UK

Health Professionals: Refer Your Patient to Us For Support

Getting the right support for your CMT patients can help their understanding of the condition, feel supported by our trained professionals, and feel less isolated with our Facebook groups.

Membership to CMTUK is now donation-based, as we strive to be an inclusive charity and to make membership accessible to all those living with CMT and related conditions, or with an interest in CMT.

Once the form is filled in, your patient will be contacted by CMTUK to let them know about the services and support we can offer them.

Thank you.

Your Patient Details

Patient Title (required)

Patient First Name (required)

Patient Last Name (required)

Patient Email address

Tick if patient doesn't have an email address
Patient Telephone Number (required)

Patient's Date of birth (we use this to match the patient information to the referral)

Estimated date of diagnosis

Reason for referral

Your Details (as the referring healthcare professional):
Your Title (required)

Your First Name (required)

Your Last Name (required)

Your Email address

Your Telephone Number (required)

Your Role (required)

Name of your organisation (required)

I (as the Health Professional) confirm the above patient has given permission to share their information with CMTUK, so they can access the referral service (required)
Yes, I consent
Any additional notes

Health Professionals: Refer Your Patient to Us For Support

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