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

Patient Details

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

Name *

Address *

Telephone Number *

NHS number *

Date of Birth *

Overseas visitor? *

Yes

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

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 designation *

Referrer email *

Contact Number *

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? *

Environment

If yes, what are the risks? Please provide details of any risks (dangerous dogs, environmental infestations, any history of offenders residing at the property etc) *

Can the patient open their door? *

Yes

If no, what is the keysafe number? *

If the patient consents to contact via email, what is the patient's email address?

If the patient consents to using Skype, what is the users Skype ID?

Clinical Detail

Number of admissions / 999 calls / A&E / GP clinic attendances in the last 12 months

Reason for Referral (as related to long term condition or high intensity user) *

Unexplained falls - frequency and any injuries sustained

Any other relevant information

Ageing Well