Patient Details

All patients with suspected Active TB should be referred Urgently to the Secondary care

Name *

Address

Telephone *

NHS number *

Date of birth *

Mobile *

Locala new entrant latent TB Screening referral form

Been on holiday for more than 6 months in any of the countries listed above?

Has he/she been in the UK for the last 5 years or less? *

Yes

County of birth *

Country arrived from *

Countries lived in last 5 years *

Date of arrival in the UK *

Are they asylum seeking and refugees? *

Yes

Who else have they travelled with? (Please do seperate referral(s))

What's their country of origin? *

Date of arrival *

Medical

Name of referrer/consultant *

Referrer contact number *

Referrer email address *

Date of referral *

Has the patient been treated or tested for TB during their visit ot the UK?

Yes

Please give details

Blood tests/any other supporting information: Upload file

Nurse-led TB Screening Service