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NHS e-Referral Service - Referral Forms

These pro-formas are for referrals to Gloucestershire Hospitals Trust only.

 

2 week ruleHearing AidGynaecologyCardiac PhysiologyRenalOrthopaedics • Orthopaedic Practitioners •  Dietetics  •  Rheumatology Diabetic MedicineSleep ServiceGeneral Information


2 Week Rule Referral Forms


All 2 week rule referrals must include the appropriate pro-forma as an attachment. The pro-forma contains the appropriate clinical information, reason for referral (letter text) and a section for basic patient information (name, date of birth, NHS number and NHS e-Referrals UBRN). This should be sent together with the practice's standard referral letter, which will contain full patient demographic information, practice details and items from the patient's medical reord if this has been set up. As all of this information can be automatically populated from the clinical system, it means that it will not have to be re-typed on the 2 week rule pro-forma. Both documents must be attached at the same time. 

Please click on the browser 'Refresh' button before downloading any of the forms to ensure that the links are to the most recent versions. 

It is recommended that these pro-formas can be downloaded and saved in an appropriate folder on your clinical server so that they can be used by all users within the practice. 

 Cancer Type

 Clinical System   

2ww Brain

Generic EMIS TPP Vision

2ww Breast (also suitable for symptomatic breast referrals where cancer is not suspected)

Generic EMIS TPP Vision

2ww Colorectal

Generic EMIS TPP Vision

2ww Gynaecology

Generic EMIS TPP Vision

2ww Haematology

Generic EMIS TPP Vision

2ww Head & Neck

Generic EMIS TPP Vision

2ww Lung

Generic EMIS TPP Vision

2ww Skin

Generic EMIS TPP Vision

2ww Upper GI

Generic EMIS TPP Vision

2ww Urology

Generic EMIS TPP Vision

 

Rapid Access Chest Pain

 Generic EMIS TPP Vision

Direct Access Hearing Aid Proformas

Gynaecology Pilot Services proforma

Cardiac Physiology Support Documents

Renal Service Support Documents

Orthopaedics

From 24th October 2011 all referrals to Hip/Knee and Spinal services should be made using one of the templates below.

Pain Scores

Further information about the Pain, PHQ9 and GAD7 scores is available below:

Orthopaedic Practitioners

 Dietetics - Refractory IBS Service

Rheumatology

Diabetic Medicine

Sleep Service

One of the key components to a successful service is a good quality referral, we have designed an aid (based around the STOPBANG Questionnaire) to help you evaluate your patients risk and whether they may benefit from referral into the sleep service. To access it click on the link below.

General Information