Dear Doctor, Referral Date: Date of referral Referral For Trauma and Orthopaedics Hips Out Patients Booking Department Knees Sandwell & West Birmingham Hospitals NHS Shoulders trust PATIENT DETAILS GP DETAILS Referring Referrer name Forename: Forename GP: Registered Registered doctor Surname: Surname GP: Practice: Registered GP address Date of Birth: Date of birth NHS No: NHS number Hosp No (if known): Gender: Gender Registered GP phone number Telephone: Ethnicity Ethnicity Address: Patient address Fax: Registered GP fax number Registered GP practice ID Practice Code: Home Tel No:Patient home address Tel No: Patient home telephone numberWork Tel No: Any special needs? Yes No If yes, which Interpreter required? Yes No If yes, please specify language Clinical Details (Please type in or Insert relevant consultations) – Please provide scores if possible : Has the patient agreed to surgery if it is considered appropriate? Yes No Has the patient had Physiotherapy Yes No Injection Yes No If yes to the above questions, please provide further details if possible? Hip Replacement / Knee Replacement / Shoulder replacement leaflet given Yes No Knees and less than 40 for Hip) Patient’s BMI: Latest BMI (should be less than 35 for
Dear Doctor, Referral Date: Date of referral Trauma and Orthopaedics Referral For Hips Knees Shoulders Out Patients Booking Department Sandwell & West Birmingham Hospitals NHS trust PATIENT DETAILS GP DETAILS Forename: Forename Referring GP: Referrer name Surname: Surname Registered GP: Registered doctor Date of Birth: Date of birth Practice: Registered GP address NHS No: NHS number Hosp No (if known): Gender: Ethnicity Gender Ethnicity Telephone: Registered GP phone number Address: Patient address Fax: Registered GP fax number Practice Code: Registered GP practice ID Home Tel No:Patient home address Tel No: Patient home telephone numberWork Tel No: Any special needs? Yes No If yes, which Interpreter required? Yes No If yes, please specify language Clinical Details – (Please type in or Insert relevant consultations) Please provide scores if possible : Has the patient agreed to surgery if it is considered appropriate? Yes No Has the patient had Physiotherapy Yes No Injection Yes No If yes to the above questions, please provide further details if possible? Hip Replacement / Knee Replacement / Shoulder replacement leaflet given Yes No Patient’s BMI: Latest BMI (should be less than 35 for Knees and less than 40 for Hip)