Please download and complete the form below to refer a patient to the Speech and Language Therapy service.
Is the person experiencing regurgitation of food/drink? Or the sensation of food getting stuck below the level of the throat after swallowing?
If so please DO NOT complete this form, but refer to Gastroenterology.
PLEASE COMPLETE ALL RELEVANT SECTIONS (incomplete referrals will not be accepted)
All completed referrals must be returned by email to email@example.com – paper referrals will NOT be accepted.