CITMS Tissue Viability Referral Form 12-18 Lennard road, Croydon, CR2 7LR Tel: 0208 274 6163 Fax: 0208 274 6167
Referral Exclusion Criteria: Please review management and referral guidance in Service information page. Diabetic foot ulcer 0.8 – 1.2 – Refer to Podiatry / Chiropody Diabetic foot ulcer and/or Doppler result between 0.5 – 0.8 – Refer to Vascular, Mayday Diabetic foot ulcer/ necrotic foot wound and/or Doppler result less than 0.5 – Refer to Vascular SAME DAY Diabetic foot ulcer and/or Doppler result above 1.2 – Refer to Vascular, Mayday
Referring Clinician Referrer Name Referring Practice Date of Referral Practice Address Tel Number Fax Number
Postcode
Patient Details Name Address NHS Number DOB Tel No (Home) Tel No (Work) Postcode Mobile Number Ethnic Origin Gender If Interpreter required what language
Service Specific Referral Information Leg ulcer Venous / Arterial / Mixed / Unknown Black heels Surgical Pressure ulcer site & grade Diabetic Leg Foot Other Reason for referral NB any black necrosis on the feet needs immediate exclusion of arterial disease and if Diabetic must be referred to vascular team immediately.
Recent treatment /Investigations i.e. swabs/Doppler/Vascular/General Surgery/ Dermatology/ Dressings/ Antibiotics
Relevant medical history
Service Information Provider details Click here
Referrer Signature: …………………………………..
Office use only CITMS Dec 09 Epex Ref Episode Date
Date: NHS Number: Referral Version: V1.0 085e018abd60a8d861714f70b7c4cb47.doc Page 1 of 2 CITMS Tissue Viability Referral Form 12-18 Lennard road, Croydon, CR2 7LR Tel: 0208 274 6163 Fax: 0208 274 6167
Date: NHS Number: Referral Version: V1.0 085e018abd60a8d861714f70b7c4cb47.doc Page 2 of 2