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About Sexual Health St. Helens Contact Us

Daisy Clinic 

We offer a walk-in service from 9:00 am to 4:30 pm, including booked appointments. To book an appointment please call 01744 646 473.
We offer a walk-in service from 9:00 am to 4:30 pm, including booked appointments. To book an appointment please call 01744 646 473.
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The daisy clinic is a pathway that allows professionals to refer patients directly into the St Helens Sexual Health clinic. Please complete the form below for the patient will be called to discuss their sexual health needs. We aim to call within 3 working days, please advise your patient that we call on a private number.  We are a confidential service so will be unable to share details without patient consent. Please note the patient must provide consent for our service to contact them.

This form is intened for non-urgent care. If your patient requires Emergency Contraception or PEP, please call clinic on 01744 646 473 MOnday-Friday 9:30am-4:30am. 

 

Does your client consent to this referral?*

Client Name

Client Surname

Client Date of Birth

Client Gender

Is their gender the same as assigned at birth?

Client address

Client contact number

Client ethnic group

Client country of birth

Client sexual orientation

Client GP name and practice

Does your client require a interpreter?

Does the patient require adjustments to attend our clinic?

Are there any safeguarding concerns that we need to be aware of?

Why are you referring this patient to clinic?

Please provide any additional information?

Referring agency

Refer name

Referrer contact number Tel

Referrer e-mail address*