Patient Details*	Referral Details*	
Name	Title Given Name Surname 	Date of this referral	Short date letter merged	
Address	Home Full Address (single line) 			
Telephone	Patient Home Telephone 	Referrer Name	Current User	
Mobile	Patient Mobile Telephone 	Practice Name	Usual GP Organisation Name	
Date of Birth	Date of Birth 	Practice Address	Usual GP Full Address (single line)	
NHS Number	NHS Number 	Practice Code	Usual GP Organisation National Practice Code	
Gender	Gender(full) 	Telephone	Usual GP Phone Number	
Email	Patient E-mail Address 	Fax	Usual GP Fax Number	
Ethnicity	Ethnic Origin      	Email (NHS)	     	
Main language or please state if deaf requiring interpreter	Main Language 
Advocacy Needs 
     	
Interpreter required?	Yes      No 	
Any other information (e.g. accessibility requirements, carer information, etc.)	Transport Needs 
Carer related codes recorded: Is a carer... 

Learning Disabilities related codes recorded: Learning disabilities administration status... 
-      	
 *Denotes mandatory field

Patient Consent*	
Patient consents to the Camden MSK service contacting by:

Text               Email           Voicemail 	

Service Requested (If you are unsure please request Specialist Triage)*	
PHYSIOTHERAPY		
SPECIALIST TRIAGE (CATS)/ORTHOPAEDICS/RHEUMATOLOGY/INJECTIONS/INVESTIGATIONS:
CATS = Clinical Assessment & Treatment Service		
CAMDEN PAIN SERVICE		
MSK PODIATRY 		
URGENT RHEUMATOLOGY: 
Inflammatory joint disease/inflammatory rheumatology conditions		
ADVICE AND GUIDANCE ONLY:
Please provide a mobile telephone number & email address which you can be contacted on to give advice and guidance here:      		
Referral Reason	
Description of primary problem, clinical findings, diagnosis (if known), treatments so far and impact on patient (sleep, work, etc):
Body Text      

Consultations	
Other Medical Problems (including any psychiatric conditions, psychological or difficulties that may affect treatment compliance): 
     

Problems 	
Current Medication:
Medication	

Referral Priority	
Urgent             Routine 

If not completed, Camden MSK will assume routine priority

If  you consider this patient a non-clinical high priority, please give further details:       	

Patient’s Hospital Choice	
The vast majority of patients are managed conservatively by community physiotherapy, but for those whose care may need to be transferred to a hospital setting, please indicate patient’s choice:   

Royal Free         UCLH        Other hospital        No preference        Shortest wait list 

If other hospital, please specify which:       	

Please tick*:	
To confirm that there are NO indicators of serious underlying pathology (Red Flags).  (Patients presenting with red flags should be referred to hospital for investigation) 
Click here to go to GP referral guidelines (including Red Flags information)		
To confirm that you are attaching all relevant hospital correspondence, blood results (last 3 months) and imaging reports.  		
Please tick if patient has had surgery or trauma in the last 6 weeks and is transferring back into Camden. Please state at which hospital surgery occurred      		

Patient’s expectation of the service:	
     	
Allergies 	Substance Misuse: Substance misuse monitoring... 	
Smoking 	Alcohol Consumption 	
Height 	Weight 	
BMI 	Blood Pressure 	
Patient educated regarding self-management and directed to self-management resources 
Patient understands they are referred to a partnership of organisations 

Camden MSK Triage Hub contact details: 0203 447 7779       Email: uclh.camdenmskhub@nhs.net

Please note that we do NOT accept referrals to this email address. 
Please refer using e-referrals.

Please visit our website: www.camdenmsk.nhs.uk