PRESSURE CUSHION REFERRAL FORM (Page 1 of 2) To be completed by a G.P., District Nurse or Therapist. Contact details; 0330 124 4485 Service site locations; Millbrook Healthcare Millbrook Healthcare Inca House Unit 1 Email; Wotton Road Ambley Green Ashford Gillingham Kent Kent Secure Email; TN23 6LL ME8 ONJ *Please complete all boxes to avoid unnecessary delays* NHS No: Client Details Title: Mr / Mrs / Miss / Ms / Master OTHER : Forenames: Surname: Date of Birth: Full client postal address: Alternative Contact/Address/Details: Name & Relationship to Client: Address/Details: Postcode: Postcode: Telephone No: Telephone No: Mobile No: Mobile No: E-Mail: E-Mail: GP Name: Address: Telephone Number: Nature of disability / any relevant information: Patient Height/Weight: Height (cm): Weight (Kg): History of Pressure Area(s) Skin Condition: 1 No Problem Red Grazing / Broken Areas Open Sore Please specify grade of pressure sore: (Refer to wound classification sheet) 2 Grade: Please specify Waterlow score: (refer to Waterlow score chart) 3 Score:
PRESSURE CUSHION REFERRAL FORM (Page 1 of 2) To be completed by a G.P., District Nurse or Therapist. Service site locations; Millbrook Healthcare Millbrook Healthcare Inca House Unit 1 Wotton Road Ambley Green Ashford Gillingham Kent Kent TN23 6LL ME8 ONJ Contact details; 0330 124 4485 Email; Secure Email; NHS No: *Please complete all boxes to avoid unnecessary delays* Client Details Title: Mr / Mrs / Miss / Ms / Master OTHER : Forenames: Surname: Date of Birth: Full client postal address: Postcode: Alternative Contact/Address/Details: Name & Relationship to Client: Address/Details: Postcode: Telephone No: Mobile No: E-Mail: Telephone No: Mobile No: E-Mail: GP Name: Address: Telephone Number: Nature of disability / any relevant information: Patient Height/Weight: Height (cm): Weight (Kg): History of Pressure Area(s) 1 Skin Condition: No Problem Red Grazing / Broken Areas Open Sore 2 Please specify grade of pressure sore: (Refer to wound classification sheet) Grade: 3 Please specify Waterlow score: (refer to Waterlow score chart) Score: