Child's detailsName * REQUIRED First Last Gender * REQUIRED Date of birthDay12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS Number Address * REQUIRED Street Address Address Line 2 City Country Postcode Is English the child's first/home language? Yes No What is their first / home language? Parent or Carer DetailsName First Last Relationship to child Home telephone Work telephone Mobile telephone Preferred telephone * REQUIRED Home Work Mobile Parent / Carer Email Health Professional DetailsGP Name GP Surgery Lead Consultant Are there any other health professionals involved in the care of the child? Yes No Please give details hereDiagnosisPlease summarise the discharge diagnosisWas the child given medication on discharge? Yes No Please detail the medication hereReason for referral / nursing needs * REQUIRED Burn Cardiac care Gastrostomy Management IV Medication Nasogastric Care Respite Care Assessment Medication Administration Sleep Study Tissue Viability Wound Care Blood specimen Other Please supply at least seven days of medication, syringes, feeding supplies, wound care packs and dressings as required, as well as a syringe pump and prescription chart if needed. Please give detailsIV Medication or Medical AdministrationDrug Dose Dose / Kg Route Time last given Total doses planned Date and time blood cultures sent What date was the IV access in place sited? If required, when was confirmation of the lines position obtained, and state length of line in situ? Has a drug chart been sent home with the patient? Any other detailsNasogastric Tube FeedingNG Tube Size6FR8FRNG tube type Tapes used Who is trained to give feeds? Mother Father Other Has training been given on changing the tapes? * REQUIRED Yes No Has training been given on passing the tube? * REQUIRED Yes No Is the Home Enteral Feeding Team (HEFT) involved? * REQUIRED Yes No Wound CarePlease send home a seven-day supply of equipment and dressings (including dressing packs) Dressings in useLocation of wound Current pain relief Please note that we are unable to accept referrals for children using EntonoxCardiac Care What are the normal/acceptable ranges of saturations? What are the normal/acceptable ranges of respiratory rate? What are the normal/acceptable ranges for blood pressure? What are the normal/acceptable ranges for pulse? Other detailsIs there a named social worker? Yes No Social worker detailsIs child on a child protection plan or in need of one? Yes No Please provide detailsIf there are other safeguarding concerns please detail hereIs there any other information you'd like to add to this referral?e.g. bloods required, any follow up planned, line dressing changes.Consent to treatmentAny referrer requires verbal consent for this referral to be made.Has verbal consent been obtained for this referral? * REQUIRED Yes No Referrer detailsReferrer name Designation Ward/unit Contact telephoneReferrer email address If you provide us with your email address, a copy of the referral form will be sent to you.