WARRINGTON BLADDER & BOWEL CARE SERVICE REFERRAL FORM Please complete Medical History and then symptom profile for either the adult or paediatric client. Please note incomplete forms will be returned to referrer as the information you provide helps us to ensure the client is triaged appropriately Patient Mrs/Mr/Miss/Other GP Name Name & Title Male/Female Address GP Address Postcode DOB: GP Tel: Tel: Patient Spoken Language: Ethnicity: NHS. NO. School Health Under care Yes/No Adviser / of If Yes please state? Health Visitor: consultant? …….......................................... Medical History Present Medical Condition Please Complete OR Attach / Fax A Print Out – Past Surgical Procedures & Dates Current Medication Please Complete OR Attach / Fax A Recent Print Out – Has the patient received treatment for the same condition before? Yes No If yes please comment Is this patient under the care of an urologist / gynaecologist? Yes No If yes please comment
WARRINGTON BLADDER & BOWEL CARE SERVICE REFERRAL FORM Please complete Medical History and then symptom profile for either the adult or paediatric client. Please note incomplete forms will be returned to referrer as the information you provide helps us to ensure the client is triaged appropriately Patient Name & Title Mrs/Mr/Miss/Other Male/Female GP Name Address Postcode GP Address DOB: GP Tel: Tel: Patient Ethnicity: Spoken Language: NHS. NO. School Health Adviser / Health Visitor: Under care of consultant? Yes/No If Yes please state? …….......................................... Medical History Present Medical Condition – Please Complete OR Attach / Fax A Print Out Past Surgical Procedures & Dates Current Medication – Please Complete OR Attach / Fax A Recent Print Out Has the patient received treatment for the same condition before? Yes No If yes please comment Is this patient under the care of an urologist / gynaecologist? Yes No If yes please comment