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Tissue Viability

  • Referral Form
  • Tissue viability service
  • Complete

Bedfordshire Community Health Services Referral Form

Telephone No.: 0345 604 4064

Please complete initial referral section and corresponding numbered section

Reason(s) for referral(s)

Does the patient have a Bedfordshire GP?

Patient Details

Address

Language & Ethnicity

Interpreter required?

Impairments to service access

Physical/Communication impairments, especially if requires assistance with arranging appointments?
Does patient require transport to attend appointments?

Next of Kin/Carer Details

Does the patient have an appointed Power of attorney for health? If Yes, name and contact number of PoA for health.

GP Details

Referral Details

Does the GP agree to notification by task that reports or letters have been written

Risk Assessment

Living Circumstances
Housebound
Able to open door
(Lone worker risks, inadequate lighting in area, secluded location, pets)
Previous or current experience of mental health issues?
Previous or current suicidal ideation/attempt/self-harm?
Known to Mental Health Services?
History of violence/aggression towards others?
Current expressions of violence/ aggression /threatening behaviour? (either by patient or others living at the same address)
Communication Difficulties

MARS Chart

Has MARS Chart been completed if being asked to administer medication
Has DNAR been completed?

Allergies

Do you have any allergies?

Hospital Discharge Referral

(if this changes Single Point of Access Must be Informed)
Unlimited number of files can be uploaded to this field.
64 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.
Type of Wound
One file only.
64 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.
Tissue type
Does wound bleed easily?
Does the patient exhibit any of the following?
Is the patient unwell/feverish

If the wound is a PRESSURE ULCER, please answer the following: