Children’s Community Atopy Service Referral Form

Referral Date: Short date letter merged
PERSONAL DETAILS
Name: Title Calling Name Surname   DOB: Date of Birth   Age: Age   Gender: Gender NHS No: NHS Number 
Address: Home Full Address (single line) Home Full Address (single line) 
Contact: Home: Patient Home Telephone     Mobile: Patient Mobile Telephone      Email: Patient E-mail Address 

GP DETAILS
GP Name: Usual GP Title Usual GP Forenames Usual GP Surname     Referrers Name: Free Text Prompt 
Practice: Usual GP Organisation Name
Address: Usual GP Full Address (single line) 
Contact: Usual GP Phone Number     Fax: Usual GP Fax Number 

CONSENT
I have obtained consent from the   to share information relating to this patient’s medical history Free Text Prompt 

PLEASE NOTE:
•	This referral cannot be accepted without consent having been obtained.
•	The Atopy nurse will not be able to view the clinical record if the patient has 'refused consent for upload to local shared electronic record (CIDR)'. (To amend, SEE EMIS Sharing Consent icon)
•	Referring GPs, please send Emis managed referral to Childrens Community Atopy service. 
 
•	Non Emis services, please forward completed form to the: Children’s Community Atopy (Asthma & Eczema) Clinic via rf.ccnatopyclinic@nhs.net
•	For any queries: 020 7830 2571

Dear Atopy nurse

Please see below consultation for further details on this child, who I believe may be appropriate for the Atopy clinic.

Consultations 
Kind regards

Yours sincerely

Usual GP Title Usual GP Forenames Usual GP Surname