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Gastroenterology Referral Form

Please select from the following before proceeding

Start new referral
Retrieve previous referral progress

Email Address

Reference Number

Verification Code (Please enter the code emailed to you)

Please complete this form, as fully as possible, with relevant information and details to support the referral.

Section 1 - Referrer's Information

*Legal First name

*Legal Last Name

*Role

Trust

*Department

*Email

*Address

*Contact Number

*Is this referral for yourself?

Section 2 - Key information about the Patient

*Legal First Name

*Legal Last Name

*Date of Birth

*Address

*Contact Number

*NHS number

*Registered GP practice

*Is an interpreter required?

Interpreter language Type

Section 3 - Reason(s) for referral

Referral Reason Priority	Referral Reason
*1st Reason

Other reason for referral

Section 4 - Consent

Consent must be sought to share personal information with Northamptonshire Healthcare NHS Foundation Trust and other organisations that can offer support relevant to this referral

*Tick this box to confirm that consent has been discussed and received

Section 5 - Medical

*Present and Past Medical History

*Medications

*Food Allergies / Intolerance

Food Allergies / Intolerances please provide details

*Weight in kg

*Height in metres

*Body Mass Index (BMI)

Weight history for the past 6 months

Communication needs

Safeguarding Concerns

Section 6 - Supporting Information

Supporting information for the referral

Bowel Symptoms (Bristol Stool Chart and Frequency)

Gastrointestinal symptoms

Please detail dietary changes and support you have already tried/discussed

Attachments

Upload supporting information

NHFT Referral Forms