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).

Referring Physician/Specialist (or “Self Referral”):

Ref First Name

Ref Last Name

Phone

Specialty

Affiliation

Patient Information:

Patient First Name

Patient Last Name

DOB

Phone

Referral Information:

Reason

Diagnosis

Medication

MedicalHistory

Allegies

Upload Recent Lab Results or Medical Reports:

LabResults

Upload Imaging Studies (X-rays, MRIs, CT scans):

Imaging

Requested Services at Duchess Hospital:

Department

Urgency

Privacy and Consent:
By submitting this referral, you acknowledge and confirm the following:

Privacy

You have obtained the necessary consent from the patient (or have the legal authority) to share their medical and personal information with Duchess Hospital for the purpose of this referral. All patient information will be kept strictly confidential in accordance with the applicable regulations and laws.

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.

Patient Referral Form

Patient Referral to the Duchess International Hospital

Health & Wellness

Duchess Partnerships