Introductions to Wellbeing Exeter can only be made by GPs for people aged 18 or over who are registered with participating Practices The following must be completed in order for us to work with your patient Patient Details Has the patient or their appointed representative given Yes No consent for their details to be shared with Wellbeing ? Select using x NHS Number: <NHS number> Patient Address: <Patient Address> Please note we cannot accept a referral without this number (dd/mm/yy) Date of Birth: <Date of birth> Please note that only patients aged 18 and over can be referred to this service Name of Patient: <Patient Name> Postcode: <Patient Address> Gender: M/F <Gender> Home Tel: <Patient Contact Details> Patient Contact Details : Mobile: <Patient Contact Details> Email: <Patient Contact Details> Referrers Details Name of person <Sender Name> Referrers Contact <Organisation Address> making referral: details: Role and place of <Sender Details> Date referral made to <Today's date> work: Wellbeing Exeter Referral Needs GP <GP Name> Patient’s GP & Practice: <Organisation Address> Please x all that apply Does the patient have any sensory Social Practical or communication issues? Are there any risks we should be Physical Emotional aware of (e.g. for lone workers)?
Introductions to Wellbeing Exeter can only be made by GPs for people aged 18 or over who are registered with participating Practices The following must be completed in order for us to work with your patient Patient Details Has the patient or their appointed representative given consent for their details to be shared with Wellbeing ? Select using x Yes No NHS Number: Please note we cannot accept a referral without this number <NHS number> Patient Address: <Patient Address> Date of Birth: (dd/mm/yy) Please note that only patients aged 18 and over can be referred to this service <Date of birth> Name of Patient: <Patient Name> Postcode: <Patient Address> Gender: M/F <Gender> Patient Contact Details : Home Tel: <Patient Contact Details> Mobile: <Patient Contact Details> Email: <Patient Contact Details> Referrers Details Name of person making referral: <Sender Name> Referrers Contact details: <Organisation Address> Role and place of work: <Sender Details> Date referral made to Wellbeing Exeter <Today's date> Patient’s GP & GP Practice: <GP Name> <Organisation Address> Referral Needs Please x all that apply Does the patient have any sensory or communication issues? Social Practical Are there any risks we should be aware of (e.g. for lone workers)? Physical Emotional
Wellbeing-Exeter-Referral-form-Systmone.docx