Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
HMR Intravenous Therapy Team (HITT)Patient Referral Form
PLEASE SEND TO [email protected] WITH MOST RECENT CONSULTATION MEDICATIONS & ALLERGIES ATTACHED
Referral Date Time Department
Patient Details
Person Referring
GP/GP Surgery
Contact Number
Patient telephone No.
Condition being treated Weight
Relevant MC&S
Allergies
Relevant Medical History &Additional care needs
Interpreter required YES/NO Home access code:
General Condition & Relevant Information
Mobile Yes / No
Lives alone independently or with carer Yes / No
Eating and drinking Yes / No
Informed consent achieved Yes / No
Home environment suitable (phone, running water, electricity, access for nurse, animals etc.) Yes / No
Patient medication
Any Risks:
For Office Use Only
Referral Received By Date Time
Acceptance Criteria Met? Yes No Referral Accepted? Yes No
CommentsInitial bloods to be taken by HITT on admission to the service, day 3 bloods then weekly thereafter.
HMR Intravenous Therapy Team (Tel. 07966 240712 / 01706 517985)
G:\HITT\HITT 2017\Rochdale 24/10/2017