LEEDS HEALTH CARE

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					                                                                                                    Leeds Community Urology
ALL FIELDS ARE COMPULSORY
                                                                                                       and Colorectal Service
TO COMPLETE                                                                                                          St Mary’s Hospital
                                                                                                                       Green Hill Road
                                                                                                                                 Leeds
Referral type                                                  
                                                                                                                            LS12 3QE
Colorectal                                                                                                          Tel: 0113 3055138
Urology                                                                                                             Fax: 0113 3055108

                                                      Patient Referral Form

                      PLEASE ENCLOSE COMPLETED SELF ASSESSMENT FORMS

Patients Full Name: ________________________________________D.O.B:______________________

Address:_____________________________________________________________________________

_________________________________________________________Postcode:___________________

Telephone Number:________________________________________Ethinicity____________________




G.P. name:_____________________________ Telephone number: ____________________________

Address: ____________________________________________________________________________

____________________________________________________________________________________




Date of referral:_______________________________________________________________________

Name of referrer:_________________________________Designation:__________________________

Department:____________________________________ Telephone Number: ____________________

Address: _____________________________________________________________________________

_____________________________________________________________________________________

Can the patient attend the local clinic? Yes/No

Access problems / moving & handling issues / safety issues for patient/staff? Yes/No

Is the patient’s house difficult to find? Yes/No If yes please give clear directions/or consider joint
visit
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Do they require an interpreter? Yes/No
_____________________________________________________________________________________
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Current Medication:




Past Medical History/ Surgery:




Reason for Referral:

				
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posted:10/1/2012
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