Department of Nutrition & Dietetics 1st Floor, Tower Wing Guy's Hospital Great Maze Pond London SE1 9RT Clinic: 020 7188 4128 Main Switchboard: 020 7188 7188 Dear Colleague/ Insert Name RE: DIETETIC ASSESSMENT (DATE) at (LOCATION-e.g. ward/ outpatient/ patients home) TITLE E.G: First appointment insert for: /Ward D/C information/ Clinic information/ GP script Patient Name: D.O.B NHS Number: Address: Reason for Referral Nutritional Diagnosis Medical/Surgical Diagnosis Relevant Medications Relevant Biochemistry Nutritional Treatment +/- medical Diet Therapy Goal/Outcome Allergies GP/Consultant/CNS/Other AHP Actions *****NUTRITION PRESCRIPTION REQUEST***** Name and Flavour Volume Unit Quantity Total Volume No of Duration Prescription ‘Patient Manufacturer per serve volume per serve packs (weeks) Type information’ per day per required for 28days for prescription 28days
Department of Nutrition & Dietetics 1st Floor, Tower Wing Guy's Hospital Great Maze Pond London SE1 9RT Clinic: 020 7188 4128 Main Switchboard: 020 7188 7188 Dear Colleague/ Insert Name RE: DIETETIC ASSESSMENT (DATE) at (LOCATION-e.g. ward/ outpatient/ patients home) TITLE E.G: First appointment insert for: /Ward D/C information/ Clinic information/ GP script Patient Name: D.O.B NHS Number: Address: Reason for Referral Nutritional Diagnosis Medical/Surgical Diagnosis Relevant Medications Relevant Biochemistry Nutritional Treatment Diet Therapy Goal/Outcome Allergies GP/Consultant/CNS/Other AHP Actions *****NUTRITION PRESCRIPTION REQUEST***** Name and Manufacturer Flavour Volume per serve Unit Quantity per day Total volume per 28days Volume per serve No of packs required for 28days Duration (weeks) Prescription Type ‘Patient information’ for prescription medical +/-