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Your experience is important to us and helps us to make sure our services provide excellent care. If you have any comments or queries about our services please see our contact us section.

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Refer a patient

Nutrition and dietetics

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Gender: * required


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We do carry out home visits for patients who are housebound, however the first contact will be by telephone with a dietician to further screen, assess and give initial dietary advice, before a home visit will be offered.


If a home visit is required, please complete the following risk assessment; if it is not fully complete, the referral may be returned.

Can the patient communicate via the telephone?



Has consent been gained from the patient to pass these details to us?


Are there risks/concerns in seeing this patient to pass on details to us?



Are there any risks/concerns in seeing this patient in their home environment, as a lone worker?



Are there any risks present in the home? eg pets, smoker, cohabitants etc



Does the patient have any personality traits/behaviours that may present as unusual?



Are there any issues accessing the property? e.g parking, gaining entry, etc



Is there any other sensitive information that may not be clear from the referral that may pose a risk when visiting the patient?




Other contact
Relationship to patient: * required



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(if different from patients)
GP details
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Emergency contact
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Referrer
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(eg. GP, consultant, nurse)
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Diagnosis and reason for referral
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(Body mass index)
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(Malnutrition universal screening tool)
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Tick if any of the following applies to the patient:



Does the patient give consent for us to do any of the following:
(tick all that apply)






We ask the following question about ethnicity to ensure that we meet the needs of the demographic population of Medway.

* required


You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

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