Professional Referral Form

Refer Someone in Your Care

Amagi Professional Referral Form

If you’re a healthcare professional, you can refer a patient or client to our Amagi Network for further information, advice and support using the below form.

PERSON WITH COGNITIVE IMPAIRMENT OR DEMENTIA (whether suspected or confirmed)

First Name

Last Name

Preferred Name

Street Address

City / Town

Parish

Country of Birth

Country of Residence

NIS Number

Contact Telephone Number

Lives Alone?

Yes No

Email Address (Please indicate if the person does not have one)

Date of Birth

Sex

Female Male Other

Race / Ethnicity

MAIN SUPPORT PERSON

First Name

Last Name

Preferred Name

Street Address

City / Town

Parish

Country of Birth

Country of Residence

Contact Telephone Number

Email Address (Please indicate if the person does not have one)

Date of Birth

Sex

Female Male Other

Race / Ethnicity

Relationship to Client

Spouse / Partner Sibling Child Other

DIAGNOSIS

Upload any associated files. Accepted file types: pdf, doc, Max. file size: 10 MB. Please only attach only relevant documents.

Title, First and Last Name of Health Professional Who Made the Diagnosis

Medical / Health Practice

REASON FOR REFERRAL

CONSENT

Who has consented to this referral?

Person with (suspected or confirmed) dementia Support person Both

Who are we contacting in response to this referral?

Person with (suspected or confirmed) dementia Support person Both

REFERRER

Name

Organisation

Position

Contact Number

Email Address

Date

If relevant, please share any additional information that will be helpful as we follow up on this case.

What Our Participants Are Saying

"The positive aspect … was really the whole process of the training … those webinars that we had, those interactions … I found them very, very useful and informative."

"[Since the training, I feel] more ready to do investigations, especially to rule out any other form of cognitive impairments. And more ready to institute treatment at an earlier time."

"[The training] has sharpened my eyes and my approach … you have to make a special effort to actually detect [cognitive impairment] because a patient will come for diverse reasons that you might not have considered linked to impairment."

Contact Us

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86-90 Paul Street, London, England, United Kingdom, EC2A 4NE
info@amagibrainhealth.org
+ 1 (876) 428-2474 (General Queries)
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461 7713 84 (VAT number)