Practice Nurse/GP Continence Referral Form Telephone: 01621 727211 Fax: 01245 397763 E-mail Address: cecs.continence@nhs.net Note: CECS services work to NHS Connecting for Health policies and can only send responses including patient identifiable details (PID) to email addresses that are approved by them. If you are not using an approved email address this may limit the response we can make by email. Date of Referral: <Todays date> NHS Number: <NHS number> Patient Details Forename: <Patient name> Surname: <Patient name> Address and Postcode: <Patient address> Date of Birth: <Date of birth> Gender: <Gender (configurable)> Home Telephone: <Patient contact details> Mobile Telephone: <Patient contact details> Ethnicity: <Ethnicity> Learning disability Physical impairment Sensory impairment Mental Health condition Longstanding illness Other Additional Information: GP Details Registered GP: <GP name> Telephone: <GP details> GP Practice or F Code: <GP details> Fax: <GP details> Please consider the type of referral you are making: - Is an assessment for the possibly leading to the supply of products the primary aim Yes for your referral? No Are you looking for treatment plans and interventions (e.g. pelvic floor exercises, Yes bladder retraining etc.) and possibly to avoid surgery? No Continence Symptoms Urinary Faecal Both Medical History (please include if recent hospital admission/surgery) Medication: Location for Assessment HOME (Why?) Clinic: Please Mark with an X all that the patient could attend the earliest appointment will then – be offered Chelmsford Braintree St Peters Witham South Halstead (Moulsham Community (Maldon) Woodham Lodge) Hospital Ferrers Referrer Details (complete if not Tick if GP patient’s GP) patient’s Name: <Sender name> Job Role: Organisation\Service: <Sender details> Telephone: <Sender details>
Practice Nurse/GP Continence Referral Form Telephone: 01621 727211 Fax: 01245 397763 E-mail Address: cecs.continence@nhs.net Note: CECS services work to NHS Connecting for Health policies and can only send responses including patient identifiable details (PID) to email addresses that are approved by them. If you are not using an approved email address this may limit the response we can make by email. Date of Referral: <Todays date> NHS Number: <NHS number> Patient Details Forename: <Patient name> Surname: <Patient name> Address and Postcode: <Patient address> Date of Birth: <Date of birth> Gender: <Gender (configurable)> Home Telephone: <Patient contact details> Mobile Telephone: <Patient contact details> Ethnicity: <Ethnicity> Learning disability Physical impairment Sensory impairment Mental Health condition Longstanding illness Other Additional Information: GP Details Registered GP: <GP name> Telephone: <GP details> GP Practice or F Code: <GP details> Fax: <GP details> Please consider the type of referral you are making: - Is an assessment for the possibly leading to the supply of products the primary aim for your referral? Yes No Are you looking for treatment plans and interventions (e.g. pelvic floor exercises, bladder retraining etc.) and possibly to avoid surgery? Yes No Continence Symptoms Urinary Faecal Both Medical History (please include if recent hospital admission/surgery) Medication: Location for Assessment HOME (Why?) Clinic: Please Mark with an X all that the patient could attend – the earliest appointment will then be offered Chelmsford (Moulsham Lodge) Braintree Community Hospital St Peters (Maldon) Witham South Woodham Ferrers Halstead Referrer Details (complete if not patient’s GP) Tick if patient’s GP Name: <Sender name> Job Role: Organisation\Service: <Sender details> Telephone: <Sender details>
Adult%20Continence%20Service%20Referral%20Form%20Systmone.docx