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

Patient Name *

Address *

Phone Number *

Date of Birth *

NHS or Hospital No *

Overseas visitor? *

Yes

Patient has consented to information sharing? *

Yes

Medical History

Optional Attachment

(Optional) - Please attach any clinical letters/any other relevant information: Upload file

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? *

Referrer Details

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

Referrers Name *

Email *

Contact Number *

Job Title

Work Base

Referral Date

GP Name *

Address *

Reason for Referral

Wound Assessment

Type of Wound *

Duration of Wound *

Wound Size *

Location of Wound *

Tissue Type *

Current Management *

Exudate *

Wound Pain *

Medication

Allergies

Waterlow/risk assesment

Mattress

Cushion

Other Equipment

Tissue Viability - NORTH and SOUTH