COVID-19

Referrers from acute settings should provide this information to best of their ability. Not doing so can slow the process down considerably.

Date of referral

Date of discharge from hospital

Hospital discharged from

COVID-19 status

Negative

Positive

Date of COVID-19 test

GP details

If contact details are incomplete the referral cannot be processed

GP name *

GP contact no *

Consultant *

Date of admission *

Date of discharge *

Optional attachment

(Optional) - Please attach any clinical letters/any other relevant information Upload file

Referrer details

If contact details are incomplete the referral cannot be processed

Referrer name *

Referrer email *

Referrer contact no *

Referral

Where is the patient on referral? *

Hospital Other

Home

If hospital, which ward?

If other, please specify

Expected date of discharge *

Diagnosis on discharge/reason for referral *

Is a GTN spray/tablet prescribed? *

Yes

If no, please explain why

Can the patient open their door?

Yes

Past medical history *

Attach discharge summary Upload file

What is the patient's support network?

Any additional information

Click here to download the Follow up/ Future Management Form

Follow up/Future Management (Complete and Attach) Upload file

Click here to download the Medication on Discharge Form

Medication on discharge (Complete and Attach) Upload file

Click here to download the Risk Factors Form

Risk factors (Complete and Attach) Upload file

Referral made to

Social services *

Long term conditions *

Community Care Teams *

Specialist Nurse (HF/COPD/Diabetes etc) *

Cardiac Rehab