Patient Referral Form

Patient Referral to the Duchess International Hospital

Use our online patient referral form to quickly and securely refer your patients for easy and optimal care coordination.

We seek to build trust and provide you with a bespoke and unique healthcare experience at the Duchess International Hospital.

You can also visit us at the Hospital at 22A, Joel Ogunnaike Street, Ikeja GRA, Lagos (see directions below).

Duchess Hospital Patient Referral Form
Referring Physician/Specialist (or “Self Referral”):
Patient Information:
Referral Information:
Upload Recent Lab Results or Medical Reports:
Upload Imaging Studies (X-rays, MRIs, CT scans):
Requested Services at Duchess Hospital:
Privacy and Consent:
By submitting this referral, you acknowledge and confirm the following:
For a detailed understanding of how Duchess Hospital manages, protects, and uses your personal data, please review our Data Privacy & Protection Policy. By proceeding with this referral, you agree to the terms and conditions outlined in the aforementioned policy.