Richmond CCG

AUDIOLOGY REFERRAL FORM

Please note – we are unable to accept referrals for patients under 16 years of age

PATIENT	REFERRER
NHS Number	~[NHS Number]	Name	~[Free Text:Referring GP Fullname]
Forename	~[Forename]	GMC/HPC/NMC No
Surname	~[Surname]	Address	~[Surgery Address Line 1]

~[Surgery Address Line 2]

~[Surgery Address Line 3]

~[Surgery Address Line 4]

~[Surgery Address Line 5]
Address	~[Patient Address Block]

~[Post Code]
Date of Birth	~[Date Of Birth]	Referring PCT Code
Telephone (Home)	~[Telephone Number]	Referring Practice Code
Telephone (Work)	Telephone No.

(for urgent clinical findings)	~[Surgery Tel No.]
Telephone (Mobile)	~[Mobile Phone Number]	Fax No.
E-mail Address	NHS.net mail only
Gender	~[Sex]	Eligible for and does require NHS funded transport?

(car transport only) Yes
Physical/Communication difficulties (specify if any):

Wheelchair user? Yes
If interpreter required, language:	The patient must be ambulant, or if a wheelchair user they must be able to transfer independently onto the examination couch.
Ethnicity: ~[Ethnicity]
PRESENTING COMPLAINT & PROVISIONAL DIAGNOSIS

Please provide as much relevant clinical information as possible to assist with the interpretation of the referral and results.

Date of referral ~[Today...]
Please can you ensure that the patients ears are clear of wax if possible before their appointment.

Has the patient previously been fitted with a hearing aid?

Date of last hearing assessment

If previous hearing assessment in last four months, please attach results.

Yes No

/ /

Please fax or e-mail this form to the InHealth Patient Referral Centre:

Fax: 0333 200 1163 E-mail: inl.inhealthreferrals@nhs.net

Tel: 0333 202 0297

www.inhealthgroup.com

EMIS PCS July 2015

INHEALTH

Caroline Meechan

2015-07-23

InHealth Ltd