HMR Intravenous Therapy Team (HITT)Patient Referral Form

PLEASE SEND TO pah-tr.RochHITT@nhs.net WITH MOST RECENT CONSULTATION MEDICATIONS & ALLERGIES ATTACHED

Referral Date Time Department

Patient Details

Person Referring

GP/GP Surgery

Contact Number

Patient telephone No.

Condition being treated Weight

Relevant MC&S

Allergies

Relevant Medical History &Additional care needs

Interpreter required YES/NO Home access code:

General Condition & Relevant Information

Mobile Yes / No

Lives alone independently or with carer Yes / No

Eating and drinking Yes / No

Informed consent achieved Yes / No

Home environment suitable (phone, running water, electricity, access for nurse, animals etc.) Yes / No

Patient medication

Any Risks:

For Office Use Only

Referral Received By Date Time

Acceptance Criteria Met? Yes No Referral Accepted? Yes No

CommentsInitial bloods to be taken by HITT on admission to the service, day 3 bloods then weekly thereafter.

HMR Intravenous Therapy Team (Tel. 07966 240712 / 01706 517985)

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