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Locations
Leigh Health Centre
Wigan Sexual Health Service
Batley Health Centre
Beckside Court- Head Office
Bingley Medical Practice
Birkenshaw Health Centre
Bowling Hall Medical Practice
Chestnut Centre
Cleckheaton Health Centre
Dearne Valley Health Centre
Dewsbury and District Hospital
Dewsbury Health Centre
Eddercliffe Health Centre
Farfield Group Practice
Fartown Health Centre
Holme Valley Memorial Hospital
Honley Surgery
Horsfall House
Howard House
Ings Grove
Kirkburton Health Centre
Kirkheaton Surgery
Lockwood Surgery
Mill Hill Health Centre
Mirfield Health Centre
Moorlands Grange
Newsome Surgery
Princess Royal Health Centre
Ravensthorpe Health Centre
Shepley Health Centre
Skelmanthorpe Health Centre
Slaithwaite Health Centre
Slaithwaite Town Hall
Somerset Buildings
St Johns Health Centre
The Choices Centre
The Orange Rooms
The Cobbles, Meltham Surgery
The Grange Group Practice
Todmorden Health Centre
Waterloo Practice
Windhill Green Medical Practice
Young Batley Centre
Consultant Adult Continence
Information required
If contact details are incorrectly input where mandatory the referral cannot be processed
Patient name *
Address *
Date of birth *
Phone number *
NHS number *
Overseas visitor?
Yes
No
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?
Name of consultant/referrer *
Referrer email *
Referrer contact no *
Referral from *
Please select
Acute
Care Home
GP Practice
Hospice
Local Authority
School
Self Referral
Patient has consented to information sharing? *
Yes
No
Patient has consented to the referral *
Yes
No
If patient is unable to consent to referral, please provide details *
Best interest decision made by (Name) *
Best interest decision made by (Phone number) *
Symptoms
Symptoms
Presenting symptoms *
Stress Incontinence
Neurogenic bladder
Bowel dysfunction (constipation or incontinence)
Pelvic floor dysfunction with associated bladder or bowel dysfunction
Bladder or bowel dysfunction due to delivery within last 12 months
Bladder/bowel problems due to delivery in last 12 months
Overactive bladder
Neurogenic bowel
Prolapse with associated bladder or bowel dysfunction
Sexual dysfunction with associated bladder or bowel dysfunction
Neurogenic bladder symptoms that require the teaching of intermittent self-catheterisation
Reason for referral / relevant information *
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