LEG ULCER CLINIC REFERRAL FORM
NHS NO…………………………………..
Referral Date: .......................................
Surgery Address:............…………………………………………………………………………..
Tel: .................……………………………………………………………………………………..
I would appreciate it if you would assess and treat (if appropriate) the following patient's leg ulcer: NAME:(MR / MRS / MS)……..……… ........………………………………..............……………
ADDRESS ...………………………………………………………………..........................……...
..........………………………………………………...POST CODE………………….
TEL NO. .............................MOBILE NO….……………………..D.O.B.................……………...
Relevant medical history: ...................................................................................................……….
..............................................................................................................................................…….
Current treatment. Right Leg.............................................................................………………….
Current Treatment: Left Leg......................................................................................…….……….
PLEASE ENCLOSE A COPY OF ROUTINE BLOODS, INCLUDING FBC, GLUCOSE, U & E.
PLEASE ENCLOSE A PRINTOUT OF ALL MEDICATION AND PAST MEDICAL HISTORY.
Previous/Current referral to a Vascular Surgeon…………………………………..…………….Yes/No
(if yes, please supply details or attach relevant communications)
Previous Attendance at Leg Ulcer Clinic…………………………………………………………Yes/No
Is the patient able to stand and transfer without the use of a hoist?………………………………Yes/No
Can the patient make his or her own way to clinic?……………………………………………….Yes/No
Signature……………………………………………Designation………………………………………...
PRINTED SIGNATURE …………………………………………………………………………………
REFERRING PRACTITIONER………………………………………………………………………….
Return to: - Community Leg Ulcer Clinic
Runcie Wing, St. Albans City Hospital
Waverly Road, St. Albans AL3 5PN
Tel: 01727 897436
Fax: 01727 897480
PLEASE NOTE: NO REFERRALS WILL BE ACCEPTED UNLESS FULLY COMPLETED.