*Indicates that this item is mandatory Clinical Information Reason for referral / Anticipated outcome:* Symptoms (including history of presenting complaints and interventions to date): * Examination findings : Relevant tests / investigations : attached not applicable Past medical history : Current medication: Allergies / Adverse medication events Relevant Family history : Relevant Social history : Additional Relevant information (including special needs, disabilities, clinical warnings) For hospital use (referral management and outcome) Date referral received : Triage outcome (priority): urgent routine Date sent for triage : Date of new attendance : Date returned from triage : Consultant clinic : Patient’s name : Patient’s date of birth : Referring GP’s name : *Indicates that this item is mandatory
*Indicates that this item is mandatory Clinical Information Reason for referral / Anticipated outcome:* Symptoms (including history of presenting complaints and interventions to date): * Examination findings : Relevant tests / investigations : attached not applicable Past medical history : Current medication: Allergies / Adverse medication events Relevant Family history : Relevant Social history : Additional Relevant information (including special needs, disabilities, clinical warnings) For hospital use (referral management and outcome) Date referral received : Triage outcome (priority): urgent routine Date sent for triage : Date of new attendance : Date returned from triage : Consultant clinic : Patient’s name : Patient’s date of birth : Referring GP’s name : *Indicates that this item is mandatory
PatientReferral.docx