Adult MSK Service Referral Proforma Please complete BOTH sides of this form in FULL and fax to Adult MSK Service. Fax: 020 8319 8560 Tel: 020 8331 3250 Section 1 PATIENT INFORMATION. Please complete in BLOCK CAPITALS. – SURNAME Patient referred to this Y N servicebefore? FIRST NAME NHS Hospital Number Number Gender M F DOB Patient aware of the referral Y N Address First language Interpreter required? Y N Post Code Transport required? Y N Daytime Telephone Home Telephone /Mobile No E-Mail Address NB: Please note we have a text message appointment reminder service. Unless opted out, patients will automatically receive text reminders. Opt Out Ethnicity: Section 2 PRACTICE INFORMATION. Use practice stamp if available. – Referring GP Date of Referral Practice Address Telephone Fax Post Code Referral information – NO LOWER BACK PAIN (acute only <6/52) Please use existing pathway for LBP. – NO PAEDIATRICS (under 16 years of age) For use of Adult MSK Service only Paper triage: □ Onward referral: ………………………………………………….……… Adult MSK Service: □ Name: Signature: Date:
Adult MSK Service Referral Proforma Please complete BOTH sides of this form in FULL and fax to Adult MSK Service. Fax: 020 8319 8560 Tel: 020 8331 3250 Section 1 – PATIENT INFORMATION. Please complete in BLOCK CAPITALS. SURNAME Patient referred to this servicebefore? Y N FIRST NAME NHS Number Hospital Number Gender M F DOB Patient aware of the referral Y N Address Post Code First language Interpreter required? Y N Transport required? Y N Daytime Telephone Home Telephone /Mobile No E-Mail Address NB: Please note we have a text message appointment reminder service. Unless opted out, patients will automatically receive text reminders. Opt Out Ethnicity: Section 2 – PRACTICE INFORMATION. Use practice stamp if available. Referring GP Date of Referral Practice Address Post Code Telephone Fax Referral information – NO LOWER BACK PAIN (acute only <6/52) – Please use existing pathway for LBP. NO PAEDIATRICS (under 16 years of age) For use of Adult MSK Service only Paper triage: □ Onward referral: ………………………………………………….……… □ Adult MSK Service: Name: Signature: Date:
Adult_MSK_Referral_Form_June_2013_1.docx