Download Community respiratory clinic referral form

Community Respiratory Clinic Referral Form
Forename:
Surname:
DOB:
NHS No:
Referral process
Fax/ E-mail completed form to:
Patient Address:
Fax: 0300 008 3133
E-mail: [email protected]
To discuss suitability contact:
Tel No: 01442 287604
Daytime Tel No:
Relative / Carers Tel No:
Diagnosis
 COPD
Reason for Referral:
 Bronchiectasis
 Asthma
Past Medical History
Medication (list or attach printout)
Drug
Dose
Frequency
Spirometry
Result
% Predicted
FEV1
FVC
FEV1 / FVC ratio
Preferred location for appointment:
Hemel Hempstead
Potters Bar
GP Details or Stamp:
Referred by:
GP Name:
Name:
Practice:
Contact Tel No:
Watford
St Albans
Edgware
Home visit
Date referred:
Community Clinic Referral Criteria:
 Confirmed diagnosis of COPD, asthma, bronchiectasis
 Condition Unstable
 Frequent exacerbations (>2 per year)
 Frequent admissions to hospital
 Clinical symptoms disproportionate to lung function tests or
clinical decline
 Problematic withdrawal of steroids
 Complex patients requiring specialist MDT review
Exclusion Criteria



Lung Cancer – cancer 2 week wait referral
Tuberculosis (new case) – WHHT referral
ILD & NIV (direct referral from acute hospital)
Patient with a current exacerbation, not responding to treatment or requiring
more intensive support will be cared for under Hospital at Home.
Please contact respiratory nurse specialist direct on
Tel: 07944 960825
for Home Oxygen, Pulmonary Rehab & OSA
complete separate community respiratory referral form