East and North Herts Integrated Community Respiratory Service Referral Form Surname Forename Main language: Dob NHS Number Interpreter Needed? Yes No Address: Does the patient have any learning disability? Yes No Does the patient have full mental capacity? Post Code: Yes No Patient consents to referral? Yes No Telephone: SystmOne share in place? Yes No Does the patient live alone? Yes No Main Carer/Next Of Kin: Is the patient a main carer for someone else? Yes No Tel number Tel number Is this patient able to open the front door? Yes No Relationship to patient: Is there a key safe: Yes No Relationship to patient: Any reason why a lone worker will be at risk? Respiratory Diagnosis: Please attach GP/Discharge summary including the latest/available spirometry results and relevant clinic letters Oxygen Saturations _________% AIR/Oxygen ________lpm Reason for referral - please select relevant option GP Practice: Admission avoidance Supported discharge Referrers Name: Complex management Job Title: Oxygen assessment Contact Number: Relevant information: Date: Time: (Please use reverse if required)
East and North Herts Integrated Community Respiratory Service Referral Form Surname Forename Main language: Dob NHS Number Interpreter Needed? Yes No Address: Post Code: Telephone: Does the patient have any learning disability? Yes No Does the patient have full mental capacity? Yes No Patient consents to referral? Yes No SystmOne share in place? Yes No Does the patient live alone? Yes No Is the patient a main carer for someone else? Yes No Is this patient able to open the front door? Yes No Is there a key safe: Yes No Any reason why a lone worker will be at risk? Main Carer/Next Of Kin: Tel number Relationship to patient: Tel number Relationship to patient: Respiratory Diagnosis: Please attach GP/Discharge summary including the latest/available spirometry results and relevant clinic letters Oxygen Saturations _________% AIR/Oxygen ________lpm Reason for referral - please select relevant option Admission avoidance Supported discharge Complex management Oxygen assessment Relevant information: (Please use reverse if required) GP Practice: Referrers Name: Job Title: Contact Number: Date: Time:
ICRS%20Referral%20form%20March%202017.docx