Person's Details

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

Name *

Gender *

Male

Female

Date of Birth *

Patient has consented to information sharing? *

Yes

Patient has consented to referral? *

Yes

Address *

Telephone Number *

Email Address

NHS Number *

Ethnicity

Overseas visitor?

Yes

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 letter/any other relevant information: Upload file

Referral

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

GP Practice Address *

Consultant *

Referrer Name *

Date of Referral

Designation *

Diagnosis

Reason for Referral *

Referrer Email *

Referrer Contact Number *

Appropriate for

HEN Clinic

Home Visit

Usual Weight (KG)

Current Weight (KG)

Height (M)

Past Medical History

Relevant Medication

Is patient aware of diagnosis/prognosis?

Yes

Has patient consented to referral?

Yes

Other professionals involved?

Any other relevant information?

Tube Information

Reason for placement

Type of tube in situ

Tube Size (Fr)

Location of tube tip

Placement hospital

Date of insertion

Plans for replacement

Spare tube provided?

SaLT Advice

Feeding Regime and/or oral intake and supplements

Nutritional Values

Additional H2O needed

Patient registered with Nutricia

Yes Pump tracking only

Nutricia nurse is involved with the patient

Yes

Home Enteral Nutrition referral form - SOUTH ONLY