CoombePrimary Care Team Referral Form

Please ensure all sections complete & consent received from Client or Parent / Guardian

Client Name
Address / DOB
Day / Month / Year
Gender / Male Female
Tel/Mobile # / Consent to receive Text messages? / Yes No
Parent/Guardian/ NOK / GP Name (or stamp) / ______
Relationship to client / Address / ______
Tel / Mobile# / Tel # / ______
Public patient card type: / Card # / Expiry Date:
Referral from Acute Services / Private Insurance / Yes No / Provider
If facilitating hospital discharge, date of discharge / / / / Hospital Medical Record #
Referral To / Tick box for discipline(s) you are referring to
Health & Social Care Professionals (PCT / HSCN) / All referrals can be faxed or posted
GP
Practice Nurse / Thomas Court
Fax: 4150161
PHN
RGN
OT
HCA
Social Work
Musculoskeletal
Physiotherapy
Psychology / South Inner City Partnership
Fax: 4545553
Dietitian
Smoking cessation
Wound Clinic / Thomas Court Primary Care Centre
1 Catherine’s Lane West
Dublin 8
Tel: 7083200
Fax: 4150161 / South Inner City Partnership,
Meath Community unit Heytesbury St,
Dublin 8.
Tel: 7085724
Fax: 4545553
Reason for Referral
Please be specific
Relevant History/ Issues of Concern
Medications
Social Circumstances / Live alone?
Interpreter required? / Yes No
Yes No / With whom?
Language
Mobility / Independent / With Aid / Wheelchair / Immobile
Other professionals involved in client’s care? Yes No Don’t know If “yes” provide name & contact details
______
Has Client (or parent/guardian) consented to this Referral? / Yes No
Has Client (or parent/guardian) consented to sharing of His/Her information? / Yes No
Referred By / Name/ Title / Date / / /
Signature / Tel #
Preferred method of contact: Telephone / Fax / Email
PCT / HSCN / OOH Co-op / Hospital Dept
Client Name: / DOB: / / Page 2

EssentialInformation for Discipline Referrals

This is not an assessment form;it is for the purpose of Interdisciplinary Referral ONLY

CHILD & ADOLESCENT REFERRALS

All Referrals
Public Health Nurse Report Available? Yes No
School attending / Class
Area Medical Officer / Nursing
Vision / Hearing / Behaviour / Parental Concern
Height /weight / Nutrition / Developmental Delay / Child Welfare
Other
Social Work - In case of Emergency, contact should be made with An Garda Siochana
Child Protection/Welfare Concerns / Children in Care / Family Support / Early Intervention / Other
Care and Custody arrangements regarding child, if known:

ALL REFERRALS

Dietetics Attachfull biochemistry report if available including: Na, K, Urea, Creat & Urinary Albumin. Please note fasting or non-fasting
Height / Weight / BMI / Glucosemmol/l / Cholesterol mmol/l
HDL/LDLmmol/l / / / TGmmol/l / HbA1C% / Hb g/dl / Ferritin ng/l
MUST / BMI Score / Weight loss Score / Acute Disease Effect Score / MUST Score
Nursing
Continence problem
Chronic Illness Management
Health Education / Promotion / Home Supports
Leg ulcer / pressure care / wound care
Nursing assessment / Preventive / Anticipatory Care
Psychological Support
Other:
Existing Pressure Sore / Yes No / Stage 1 2 3 4 / Waterlow Score
Has the client had a recent fall or at risk of falls? / Yes No
Assessments: / Barthel Score / / 20 / MMSE Score / / 30 / EPDS Score / / 30
PhysiotherapyOccupational TherapyAttach copies of X-rays, MRI, DEXA scans, etc if available
How long has the client had complaint? / 1-2 Weeks 2-4 Weeks 1-3 Months 3-6 Months 6+ Months
Is the problem getting / Better Worse Unchanged / Pain: / Yes No
Is the client experiencing difficulties with: Activities of daily living Work Leisure Yes No
If yes please specify
Is the client experiencing difficulty with their / Memory / Home Environment / Mobility and transfers / Seating and posture / Mood & anxiety / Other / Please specify
Has the client a history of falls or at risk of falls
Would the client benefit from: Rehabilitation Health Education and promotion
Equipment Breakdown / Yes No / If Yes, explain
Any other relevant information:
If the referrer is an OT please summarise previous assessments and interventions.
Retain a copy of this form for record keeping & audit purposes

PCCC Referral Acknowledgement

Please acknowledge that you received the Referral by completing and signing below,

then return to Referral source (copy to client, as appropriate)

Client Name: / DOB: /
Referral Source / Name / Title:
PCT / Specialist Service / OOH Co-op / Hospital Dept:
Preferred method of contact: / Telephone / Fax
Email
Referral Recipient / Name / Title :
PCT / Specialist service / OOH Co-op

Please be advised that the attached referral has been received and (Please tick appropriate box)

The referral is accepted Estimated date of client assessment: / /
Or
The referral is not proceeding for the following reasons:
Consent not completed in referral form / Inadequate information provided in referral form / Inappropriate Referral / Client declined service
Client ineligible for services / Waiting list time inappropriate for client / Other:
Comments and any further actions undertaken:
Name / Job Title / Date: / /