St Margarets Hospice - Referral Portal

Create Referrer

External Access Request Form

First name

Last name

Enter your title / role. e.g. Administrator, GP, District Nurse, Consultant etc.

Contact no

Organisation

Access type

Please enter the day of your birthday (e.g., 1-31).

Day of birth

Please enter the month of your birthday (e.g., 1 for January, 2 for February, etc.).

Month of birth

If you have a GMC or NMC number, please enter it here. It's mandatory if you possess one.

Gmc nmc number

To faciliate deployment of the S1 application please provide your computers asset number.

Asset number

Please provide the contact name and number of your organisations Data Protection Officer

Dpo details