Child's details

If contact details are incomplete the referral cannot be processed

Child's name *

Parent/carer's name *

DOB *

NHS no *

Religion

Child's current address *

Postcode *

Tel no *

Email address *

Skype ID

Ethnicity

Next of kin

Overseas visitor?

Yes

GP name *

Consultant

Consultant specialism *

Consultant location *

Please state all the languages spoken at home *

Is an interpreter needed for child/carer/parent? *

Yes

If Yes, for what language?

Are there any communication needs for this child 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 child or their parent/carer?

Consent for contact by email *

Yes

Referral discussed with parents *

Yes

Do parents consent to referral? *

Yes

Patient consented to information sharing? *

Yes

Please tick to confirm that the parent/carer consents to their child receiving assessments and interventions, as is appropriate to this referral:

The parent/carer should be aware that if at any point they do not want further treatment or interventions, they must inform their clinician:

Name of school/nursery

EHC plan or statement

Yes

Diagnosis/medical history/medications/allergies

If required, has a referral been made to any of the following prior to discharge?

Dietician Physiotherapist Other

Occupational Therapist Speech and Language Therapist

Referrer name *

Referrer email *

Referrer contact no *

Referrer job title *

Optional attachment

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

Community Nursing

Referral to

Generic

Dermatology

Discharge date *

If surgical: date of surgery?

Type of suture *

Reason for referral *

Date of first visit?

Frequency of visits *

Medications at discharge *

ALL - equipment/dressings to be supplied for 7 days (including dressing packs, solutions, primary and secondary dressings etc)

Any additional information

Children's Community Nursing NORTH ONLY