Highland Sexual Health

Referral for Partner Notification to Community Sexual Health Adviser

Patient details – use sticky label

Name

Address

Town

Post Code

D.O.B

A urine/self taken swab/endo cervical swab test (please delete appropriately) has been taken for Chlamydia testing from you today.

If the result is positive we would like to contact the Health Advisor, as you will require discussion regarding your treatment and further advice. The Health Adviser will contact you by whichever way is most convenient for you (Mobile telephone contact is preferred for confidentiality reasons) I also agree to the Health Adviser entering this information onto Highland Sexual Health’s confidential computer database.

My contact telephone number are:

Mobile Tel. no…………………………………… Home Tel. no…………………………………….

I consent to the above

Patient signature………………………………………………… Date..…………………

Staff signature/Print name ………………………………………… Date......

CLINICIAN REFERRING – PLEASE COMPLETE ALL INFORMATION BELOW Date diagnosis given ……. / ……. /…….. Pregnant Yes No

Any treatment given Yes No (Remember to screen & treat if the person is a contact of chlamydia) Date treated ……. /…… / …… (It is the Clinicians’ responsibiltity to ensure treatment has been prescribed, this is not the responsibility of the Health Adviser)

If yes what medication and dose ………………………………………………………………………… Additional info:

Send this completed form with a copy of the positive Chlamydia result if available to

West, South and Mid Operational Units - Fiona MacKinnon - Community Specialist Sexual Health Nurse Adviser, NHS Highland, Dr MacKinnon Memorial Hospital, Broadford, Isle of Skye, IV49 9AA. Tel. 01471 820340 or mobile no 07776160480 Email - [email protected]

North Operational Unit - Louise Paterson, Community Specialist Sexual Health Nurse Adviser, NHS Highland, Caithness General Hospital, Wick, KW1 5NS. Tel - 01955 605050 ext – 280 Mobile – 07770683575. Email - [email protected]