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Dietetic Outpatient

Before you begin

Is the patient housebound? *

Yes

No

If yes, your referral will be rejected.

Patient Details

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

Name *

Address *

Telephone number *

NHS Number *

Date of Birth *

Mobile Number *

Patient has consented to information sharing? *

Yes

No

Patient has consented to referral? *

Yes

No

Referrer Details

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

Referrer name *

Relationship to patient *

Email *

Contact details *

Reason for referral *

Nutritional Support Advice (MUST SCORE 2+) Newly diagnosed coeliac disease or who need a review of their gluten free diet Diet only referrals who are actively attending Consultant appointments at HRI

Gastro intestinal disorders/conditions who need dietary advice to improve their symptoms Dietary advice for irritable bowel syndrome (including the low FODMAP diet). The patient should have a confirmed diagnosis of IBS and had blood tests rule out other digestive disorders e.g. coeliac disease, inflammatory bowel disease Other

Please provide additional detail to support your reason for referral: *

e.g. patient medical history, height, weight

If appropriate, please provide further information

What is the patient’s main spoken language? *

Is an interpreter needed? *

Yes

No

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

No

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

Are there any relevant risk factors? *

Yes

No

Please attach the consultant letter here: Upload file

0300 304 5555

Information for GPs Careers General Enquiries

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