Please complete this form in full as incomplete/illegible forms will be returned and this will delay the referral.
All referrals must be accompanied by a copy of the EMIS summary.
PATIENT DETAILS
Title: / Forename(s): / Surname(s):
M F / NHS Number: / D.O.B:
Address (incl. postcode):
Daytime contact mobile telephone number:
Landline telephone number:
(We may contact the patient from a withheld number to discuss this referral) / Email address:
Alternative contact / Next of Kin name & number
Is an Interpreter required: NO YES If yes, which language:
Does the patient have a significant learning disability? NO YES List details
Any recent / known safeguarding issues (adults and children) NO YES If yes, please provide details
Is the patient housebound? NO YES
Is the patient able to answer the door – yes / no / not applicable
If no, please provide access details
Has this referral been discussed with the patient YES NO
Does the patient have any sensory impairment? YES NO If yes, please provide details
ETHNICITY
White British / Any other mixed background / Black/Black British Caribbean
White Irish / Chinese / Black or Black British African
Any other White / Asian or Asian British Indian / Any other Black groups
Mixed: White/Black Caribbean / Asian or Asian British Bangladeshi / Any other ethnic group
Mixed: White & Black African / Asian or Asian British Pakistani / Declined to state ethnicity
Mixed: White & Asian / Any other Asian background
I WOULD LIKE THIS PATIENT TO BE SEEN BY:
Integrated Locality Team (planned domiciliary care)
Community Nursing / Diabetes Clinical Nurse Specialist / Heart Failure Clinical Nurse Specialist
Continence Clinical Nurse Specialist / Domiciliary Physiotherapist / Respiratory Clinical Nurse Specialist
Tissue Viability Clinical Nurse Specialist
Please assess and advise re which of the ILT services would be most appropriate
Specialist clinic based services for patients who can attend clinics
Contraception and Sexual Health (CASH) / Diabetes Nurse Specialist / HIV Clinical Nurse Specialist
Continence (adults and children) / Diabetes Dietitian Specialist / Pulmonary Rehabilitation
Heart Failure Clinical Nurse Specialist / Diabetes Consultant / Respiratory Clinical Nurse Specialist
Please assess and advise re which of the clinic based services would be most appropriate
Therapy and Rehabilitation Services
Community Dietetics / Falls Prevention / Outpatient physiotherapy
Community Neurotherapy / MSK / Podiatry
Community Rehabilitation Team / OPARS consultant / Podiatric Surgery
Dysphagia Team for adults with LD / OPARS rehabilitation / Speech and Language Therapy
Please assess and advise re which of the therapy services would be most appropriate
Children’s Services:
Check it Out / Children’s Occupational Therapy / Health Visiting
Children’s Dietetics(incl enteral feeds) / Children’s Speech and Language Therapy / Immunisations
Children’s Physiotherapy / Family Nurse Partnership / School Nursing (incl enuresis)
Please assess and advise re which of the children’s services would be most appropriate
November 2106 Sutton GP referral formversion 2
CURRENT PROBLEM / PRESENTING COMPLAINT / REHABILITATION GOALSRELEVANT MEDICAL HISTORY
RELEVANT INVESTIGATION RESULTS
Date first visit required (Community Nursing only):
(referrals received after 4pm may not be dealt with by a clinician until the next day)
To ensure clinical safety, you maybe contacted for further information.
Please attach the following specific information:
EMIS Summary (required for allGP referrals)
Syringe pump documentation (required for syringe pump referrals)
Community IV antibiotic therapy referral form (required for administration of IV antibiotics)
X-ray reports (where relevant)
Relevant blood results (eg Diabetes require the past 12 months of blood results)
Echo report for diagnosing Heart Failure.
Please provide the following specific information:
For OPARS and Falls Prevention only - Istransportrequired? NO YES
For Falls Prevention referrals only – please tick one box: Exercise class high Exercise class intermediate Home Response
For Dietetics only - height weight weight history past 6/12
For children’s referrals
Name of school
Name of person with parental responsibility
Contact details of person with parental responsibility
REFERRER DETAILS
Date of Referral: / GP/Consultant/Referrer Name:
Contact Number: / Fax Number:
Address:
NHS.net email address: / GP Practice:
Please return this referral form along with the requested accompanying information to the Sutton Administration Centre by:
Email: We will acknowledge receipt of your referral by email if you request a “read receipt”.
Fax: 0208 661 3910. You should satisfy yourself that the fax has successfully been received by either checking your local fax log or calling our admin team on 0208 661 3908
November 2106 Sutton GP referral formversion 2