Initial details

Please note that incomplete referrals will result in rejection.

Please fill in the COVID-19 Yorkshire Rehab Screen (C19-YRS) available here, you will be asked to attach this later on in this form.

Date of referral: *

Time of referral: *

Hour

Minute

Referring from: *

Acute

Estimated Discharge Date: *

Current location of patient (e.g. if acute, hospital name and ward):

COVID status: *

Yes Unknown

Date of COVID Test: *

Referrer details

Referrer name: *

Referrer designation: *

Referrer contact details telephone: *

Referrer contact details e-mail: *

Referrers relationship to patient (e.g. consultant, therapist): *

Next of kin

Next of kin name:

Next of kin relationship:

Next of kin address:

Next of kin telephone:

Next of kind email:

Key holder?

Yes

Consent to be contacted:

Yes

Yorkshire Rehab Screen (C19-YRS)

Please attach your COVID-19 Yorkshire Rehab Screen (C19-YRS) document: * Upload file

GP details

GP surgery: *

Address: *

Postcode: *

Telephone number: *

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? *

Post COVID Syndrome Assessment Referral Form

Important Information

Post COVID Syndrome Assessment Referral Form

Hour

Minute