Child's detailsName * REQUIRED First Last Gender * REQUIREDChild's weight in KilogramsDate of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NHS NumberAddress * 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 childHome telephoneWork telephoneMobile telephone * REQUIREDPreferred telephone * REQUIRED Home Work Mobile Parent / Carer Email Health Professional DetailsGP NameGP SurgeryIs the GP in Gloucestershire? Yes No Lead ConsultantAre 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. Have all necessary supplies been supplied? Yes No Has the prescription/drug chart been sent home? Yes No N/A Please give detailsIV Medication or Medical AdministrationDrugDoseDose / KgRouteTime last givenTotal doses plannedDate and time blood cultures sentWhat 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 Size5FR6FR8FR10FRNG tube typeTapes usedWho 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 woundCurrent pain reliefPlease 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 nameDesignationWard / unit / hospitalContact telephoneReferrer email address If you provide us with your email address, a copy of the referral form will be sent to you.NumberSupporting documentsPlease upload an supporting documentation for this referral Drop files here or Select files Max. file size: 64 MB. CAPTCHA