Referral form for Paediatric Surgery - Alder Hey
Please discuss with the paediatric surgical registrar on call (Alder Hey switch 0151 228 4811bleep 331) then fax this form to 0151 252 5677 weekdays, 8-5 OR 0151 252 5193 out of hours
Patient Name...................................................................... Date of Birth .....................................................
Date of Referral ................................................................Time of Referral .................................................
Referring Consultant ......................................................... Hospital .............................................. ..........
Name of referring doctor ..................................................................................................Cons / ST... / FY...
Contact details ..............................................................................................................................................
Is the patient currently an Inpatient
Yes / No
If inpatient, Ward ...............................................
Clinical diagnosis : ..........................................................................................................................................
Brief clinical details (include relevant investigations) :
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NEONATES:
Gestation .................... Days of age ..................... Birth Weight .................. Current Weight .....................
Ventilation: Yes / No / CPAP
Rate ....................... Pressures ....................... Oxygen .......................
Hb....................... Platelets....................... Lactate....................... U&E....................... ....................... ........
Where is Mum ....................... ....................... ....................... ....................... ....................... .......................
Parents contact number ....................... ....................... ....................... ....................... ....................... ........
Mum / parents advised re providing EBM? Yes / No
Mum expressing? Yes / No