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Leigh Health Centre
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Obstetric Trauma
Information required
If contact details are incorrectly input where mandatory the referral cannot be processed
Patient name *
Address *
Date of birth *
Phone number *
Next of kin
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 referral *
Yes
No
If patient is unable to consent to the referral, please provide details *
Best interest decision made by (Name)
Best interest decision made by (Phone Number)
Optional attachment
(Optional) - Please attach any clinical letters/any other relevant information
Upload file
Condition
Date of delivery *
Presenting condition *
3rd degree tear
Ventouse
Shoulder dystocia
4th Degree tear
Forceps
Any other information
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