Wessex Facial Nerve Centre referral form

Wessex Facial Nerve Centre
Referral form
To allow us to ensure your patient is seen as quickly as possible by a member of the multidisciplinary team, your
referral will be triaged using the information you give us. Further investigations may be requested prior to your
patient’s appointment.
Patient name:
Date of birth:
GP Name and phone number
NHS number
Patient Address:
Referring Consultant name and address:
Other teams already involved – Please circle - Maxillo Facial, Ophthalmic, Oculoplastic, ENT, Otolaryngology,
Neuro/Skull base surgeons, Plastic Surgeons, Neurophysiologists Facial Rehabilitation Therapists, Audiology
Other – please specify
Brief history of presenting condition:
Ear, nose and throat and Otolaryngology Surgeons
Neuro/Skull base surgeons
Plastic Surgeons
Previous Facial/Eye operations, nerve repairs
Facial Rehabilitation Therapists
Skull Base, ENT, Ophthalmology
Please attach relevant examination findings including previous radiological investigations such as X ray, MRI and
orthopaedic interventions with dates and where performed:
Past medical history (including if have pacemaker, internal hearing device, intracranial vessel clips, metallic
implants, history of metal/foreign objects in eye or pregnant):
List of current medication:
Wessex Facial Nerve Centre, Mailpoint 101, Wessex Neurological Centre, Tremona Road, Southampton, SO16 6YD
Fax:02381204148, Email: [email protected]