Group 1

Catheter Hub referrals need to be completed by a health care professional

Do you have the consent of the person you are making a referral for? *

Yes

Do you have their consent for their information to be shared with organisations that may provide care for themselves? *

Yes

Are you making this referral as part of a best interest decision? *

Yes

We cannot accept a referral without the referee gaining consent.

Patient details

What is the name of the patient? *

What is their date of birth? *

What is their NHS number? *

What is their address? *

What is their best contact number or that of their representative? *

Referee Details

Referrer Name *

Referrer email *

Referrer Contact number *

Communication needs

What is the patients main spoken language? *

Are they in need of an interpreter? *

Yes

Does the patient have any additional communication needs? For example impaired vision or sight or any needs related to learning disabilities.

Environment

Is the patient housebound? *

Yes

Does the visit require two members of staff? For example if the patient needs to be hoisted

In a home visit are the any additional risks to staff? *

Yes

Can the patient open the door? *

Yes

If no, what is the key safe number?

Urgency *

Within seven days

Non urgent

Catheter Hub/Home Catheter Care