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Referral form ENT Emergency Clinic Date of referral:__________________________ Patient Details GP Details Name:_____________________________________ Name:_____________________________________ Address: __________________________________________ Address: __________________________________________ __________________________________________ __________________________________________ *Contact Tel No:_____________________________ Contact Tel No:_____________________________ *Second Contact Number:______________________ *Mandatory – we will only make contact via telephone If referral made from A&E, please ensure notes are attached Reason for referral: please tick appropriate box Otitis Externa requiring micro-suction Foreign bodies in the ear Recurrent Acute Epistaxis Sudden sensorineural hearing loss Fractured nose (to see within <7 days of injury) Isolated facial palsy With parotid lump send as TWR With ear infection send to A&E Other (all to be discussed with ENT SHO on call bleep 6163, or ENT SpR via switchboard Clinical History/Examination:________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Treatment received so far: __________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Please note that the ENT SHO led Emergency clinic offers emergency appointments specifically for the above criteria. All other conditions must be discussed with the on-call team. This form will be sent back if the referral is not suitable for our Emergency Clinic Email to: [email protected] Fax to: 0208 266 6777
