EMIS Forms


August 2020 update: We are currently updating this page to contain the latest forms, however, if you don't find what you are looking for, please check the relevant service page.

For any support or help installing, please email the IT & Systems Team

Use Ctrl + F if you can’t find what you are looking for.


See the Cancer section above for the following forms: 

  • Rapid Diagnostic Centre (RDC) for Non-Specific Symptoms Suspected Cancer Referral Form 
  • Urgent Direct Access Imaging Request Form (adult and paed) - Suspected Cancer - NCL FORM_V4 

Bone Density Scan Request Form - RF (March 2020)

Camden Community Phlebotomy Referral Form (22 October 2020)

Camden DXA Referral Form – In Health (April 2021)

Camden MRI Referral Form (Non MSK) - In Health (April 2021)

Camden X-RAY Referral Form (Non MSK) – In Health (April 2021)

CT MRI Imaging GP Direct Access Request Form - UCLH (April 2021)

Direct Access Referral Form – 24 blood pressure monitoring – RF (May 2021)

Direct Access Referral Form – 24 ECG monitoring – RF (May 2021)

Direct Access Referral Form – Echocardiography – RF (May 2021)

Direct Access Referral Form - 5 day loop monitoring – RF (May 2021)

Direct Access Referral Form – ECG request – RF (May 2021)

DVT Ultrasound Request Form RFH (28 February 2019)

ECG - GP Request for Cardiac Investigation - Whittington (February 2021)

GP Request for Cardiac Investigation - Whittington (February 2021)

Gynaecology Ultrasound GP Request Form - UCLH (April 2021)

Imaging - Request for Urgent Ultrasound (Non-Cancer) - RF (March 2021)

InHealth Physiological measurement referral form (including Echocardiography) (March 2021)

Ultrasound NCL CCG Referral Form - Inhealth (V3, June 2021)

NCL CCG MRI Referral form (Bariatric/Claustrophobic Service) - Open Scanner – In Health (April 2021)

NMUH GP Ultrasound Request Form (March 2021)

NMUH MRI Request Form (March 2021)

NMUH Radiographic Procedure Request Form (March 2021)

Nuclear Medicine Referral Form - UCLH  (April 2021)

Physiological measurement referral form (including Echocardiography) (March 2021)

Renal Colic non-contrast CT KUB referral form (28 January 2020)

Request for Cardiac Investigation - UCLH form (March 2021)

Routine (Non-MSK or H&N) Ultrasound Imaging Request Form (Adult and Paed) - RF (March 2021)

Whittington Health Imaging Referral Form (March 2021)

X-Ray, US and Fluoro Imaging GP Direct Access Request Form - UCLH (V2, June 2021)

 All other forms (in alphabetical order) 

Adult ADHD Referral Form - Camden & Islington (v1, June 2021)

Anticoagulation Service – RFH v.2.1 (10 February 2014)

Audiology Assessment London Hearing AQP Over-50s Referral Form (28 November 2013)

Audiology Assessment RF or RNTNE Under-50s Referral Form  (8 July 2013)

ASD referral form (v.1, May 2021)

Bereavement service referral form - Camden, City, Islington and Westminster (2 February 2021)

Bladder and Bowel Care Service (Incontinence) (December 2017)

BREATHE Smoking Cessation Referral Form  (March 2021)

CAMHS Eating Disorders Referral Form - NCL - RFL (v2, July 2021)

Camden and Islington Wheelchair Service Referral Form

Camden Care Navigation and Social Prescribing Service Referral Form v1.1 (1 September 2020)

Camden Carers Professional Referral Form (22 October 2020)

Camden Children's Physiotherapy Referral Form RFH (9 November 2018)

Camden Community Children's Services SPOR Form (December 2017)

Camden Community Drug Treatment Service Referral Form (10 March 2020)

Camden Community Health Podiatry Referral Form (December 2017)

Camden Community Health Referral Form – CNWL (October 2020)

Camden Integrated Care Service Referral Form (14 March 2016)

Camden Learning Disabilities Service (CLDS) Referral Form (14 December 2020)

Camden MSK Referral Form (v.1.4) (28 February 2019)

Camden Primary Care Mental Health Network (CPCMHN) (April 2021)

Camden Sport and Physical Activity Service

Catheter Clinic Referral Form – CNWL (4 January 2019)

Children's Community Atopy (Asthma & Eczema) Clinic Referral Form v.1.2 (5 July 2017)

Child Weight Management Service (27 April 2016)

COPD Screening Form (3 February 2014)

Coil and Implant Service JWP referral form (October 2021)

Community Health Podiatry Referral Form - Dec 2017

Diabetes Prevention Programme Referral Form NCL 2021 (October 2021)

Diabetes Prevention Programme Referral invitation letter (8 September 2020)

Digital Weight Management Referral Form - NCL - NHSE (October 2021)

Direct Access RFH/RNTNE Audiology Proforma (8 July 2013)

Drug and Alcohol Service Referral Form (19 November 2013)

ENT Urgent Referral Clinic (URC) – UCLH (July 2021)

Early Pregnancy Assessment Unit (EPAU) (May 2021)

Exercise Referral and Adult Weight Management Referral Form V.2 (21 March 2021)

Facial Pain Clinic – UCLH Referral Form (3 September 2018)

iCope Referral Form (6 April 2016)

IESO Patient Referral Form - cognitive behavioural therapy (5 April 2021)

Infertility Referral Form – Camden CCG v1 (13 August 2020)

Imperial College (St Mary's) Pathology Request Form (10 February 2014)

IRIS Camden Referral Form (29 December 2017)

London Hearing AQP Referral Form (9 December 2013)

Minor Surgery DES Referral Form NCLCCG (Camden) v1.2 (September 2021)

MOSAIC SCAS Referral Form (24 April 2015)

MSK Pain Assessment and Management Service (CPAMS) (December 2017)

NCL Anticoagulation Referral Form

NCL Maternity Services and Information Sharing Referral Form (21 February 2018)

NCL SMR patient invitation letter v1.1 (25 February 2021)

NHS Low Calorie Diet Referral NCLCCG v8.1 (October 2021) 

NLP Perinatal Mental Health Referral Form (21 February 2018)

NOAC Referral Form – Royal Free v.1 14 July 2015

Neurophysiology Referral Form - Royal Free (15 March 2018)

North Central London Diabetic Eye Screening Programme Referral Form (16 December 2020)

Paediatric Dentistry Referral Form GP (under 15) - NCL - Whittington (v2, July 2021)

Pain Management Centre UCLH (11 September 2018)

Palliative Care Referral Form

Pelvic Health Physiotherapy Referral Form (28 June 2018)

Podiatry Referral Form – RFH (24 July 2018)

PoLCE Referral Form v.5.1 (13 February 2019)

RACPC referral form April 2021 (April 2021)

Rapid Access Chest Pain Clinic – Royal Free (3 September 2018)

Rapid Response Team – CNWL referral form (April 2016)

Referral to the Child, Young Adult and Family Services - Tavistock & Portman (May 2020)

Rehab and Reablement Referral Form - August 2017 (August 2017)

Renal Colic Referral Form (20 March 2018)

Sleep Clinic referral

Special Care Dentistry Referrral Form (16+) - NCL - Whittington (v2, July 2021)

Specialist Perinatal Mental Health Services Referral - NCL (May 2021)

Support After Suicide Referral Form (April 2021)

Teledermatology Referral Form – NCL_APR2020 (April 2020)

Telederm Referral Form – Enfield – NCL (v2.8, June 2021)

TIA Service at the Royal Free (13 July 2018)

TIA Service at UCLH (13 July 2018)

Trypanosoma cruzi serology request form V1 (February 2021)

Urgent ENT Clinic UCLH RNTNE (11 February 2019)

Urology (Routine) Referral Form (20 March 2018)

Veterans Mental Health Transition, Intervention and Liaison (April 2021)

Weight Management Referral Form Camden - Slimming world (September 2021)

Weight Management Services (Adult) Referral Form (5 July 2017)

Wish+ Referral Form (5 February 2015)

About these forms

The latest pre-formatted referral forms for your practice systems are listed on this page - most of the new forms we're getting are now ready for EMIS Web systems only.

Once you have installed the referral forms on your system, you can edit them to reflect practice details. See the document on installing referrals forms for EMIS Web.

The IT & Systems team will be able to help you with problems relating to these referral forms and getting them to work with your practice system. 

e: nclccg.itandsystems@nhs.net