Buckinghamshire Community Dermatology Service-Teledermatology

Buckinghamshire Community Dermatology Service - Teledermatology Patient Details Name: «PATIENT_Forename1» «PATIENT_Surname» Tel (Daytime): «PATIENT_Main_Comm_No» Date of «PATIENT_Date_of_Birth» Tel (Mobile): Birth:Gender: «PATIENT_Sex» Email Address: NHS No: «PATIENT_New_Format_NHS_Number» Ethnicity: Address: «PATIENT_BlockAddress»

GP Details: GP Name: «~[Referring Doctor]» GP Telephone Number «PRACTICE_Main_Comm_No» Address: «~[Surgery Address Line 1]» GP Fax No: «~[Surgery Address Line 2]» Date of referral «REFERRAL_Event_Date» «~[Surgery Address Line 3]» «~[Surgery Address Line 4]» Date Referral Received «~[Surgery Address Line 5]» This service accepts referrals for: 1. Localised skin rashes where there is uncertainty/doubt about the underlying diagnosis 2. Skin lesions where there is diagnostic doubt and referral is warranted to exclude a skin cancer or underlying inflammatory process Do not refer suspected cancers (squamous cell carcinoma/malignant melanoma) 2WW Patient clinic location choice (you may tick more than one clinic location): Choice offered: North Bucks Sites: South Bucks Sites: Any North Buckinghamshire Site: Any South Bucks Site: Poplar Grove Surgery Amersham Health Centre Hughenden Valley Surgery Bedgrove Surgery Rectory Meadow Surgery Southmead Surgery Wellington House Surgery Chequers Surgery Hawthornden Surgery Brill Surgery Highfield Surgery Masonic House Surgery Brief Clinical Details (including past history where applicable): «MEDICAL_HISTORY»

Location of lesion(s): Co-ordinates of the lesions – using the diagram on right eg. D7 = front of right shoulder R21 = back of right knee L7 = nose.

Medication: «REPEATS» Allergies: «DRUG_ALLERGY» This patient has chosen the following secondary providers, should a hospital appointment be required: 1. 2. 3. Referral via Choose & Book (preferred) or fax the completed form to 01494 461184 Please ask patient to contact CV Health after 2 working days to book appointment – see leaflet

Version: Vision V1.0 July 2013 Page 1 of 1 «PATIENT_Forename1» «PATIENT_Surname»