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

Reasons for Referral

If contact details are incorrectly input where mandatory the referral cannot be processed

Patients name *

NHS number *

Overseas visitor? *

Yes

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

Date of Birth *

Address *

Postcode *

Reason for referral *

Communication

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

Are there any communication needs for this patient or their parent/carer? For example, related to learning disabilities or autism or due to impaired sight/ hearing or any other reason/s. *

Yes

What might be helpful when communicating with this patient or their parent/carer? *

Optional Attachment

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

Referrer Details

If contact details are incorrectly input where mandatory the referral cannot be processed

Referrer name *

Referrer email *

Telephone number *

Supporting Documents

Spirometry result Upload file

Chest x-ray report Upload file

List of current medications/adverse drug reactions/allergies Upload file

COPD - NORTH ONLY