Sexual Health Service Request Form Over 18's Only

Sexual Health Service Request Form Over 18's Only

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Reason for Referral
HIV Treatment & Care

HIV referrals cannot be submitted via this form.

New HIV referrals for treatment and care must be made via email dbth.snowdrop@nhs.net

Please ensure you include: Patient Name, Patient Address, Patient Date of Birth, Patient Contact Number, Patient Email, Patient registered GP Address, reason for referral and all contact information of referee.

No referrals for HIV treatment or care will be actioned via this form.
Name of referring service:

Other
Name of Referring Service:
Referring Service
Patient Full Name:

First NameLast Name
Patient Date of Birth:

DayMonthYear
Patient under 18?
Patient with no fixed abode:
Country of Birth
Translator Required
Patient Home Address/ Address on Release:

Street Address

Street Address Line 2

CityCounty

Postcode
Patient Email Address
example@example.com
No Patient contact number:
Patient Contact Number :
Mobile or LandlineFormat: (00000) 000000.
Patient consented contact:

Name and Relationship to PatientContact Number
Patient with no registered GP :
Patient GP Address:

Practice Name

Street Address Line 2

CityCounty

Postcode
Patient consents to information sharing with other professionals involved in their care e.g. Amber Project, GP:
Referral Details:
Please give as many details as possible e.g. contraception method/ GUM symptoms/ GUM positive results/ GUM treatment
Referral for:
Partner Notification:
Partner Name

First NameLast Name
Partner Date of Birth

DayMonthYear
Partner Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Partner Contact Number
Please enter a valid phone number.Format: (00000) 000000.
Multiple Partners
Please include Partner Name, Partner Date of Birth and Partner Contact Number per each contact if known
Have you completed the Patient Under 18 proforma?
Consent Gained to Contact Partners
Consent Gained to Disclose Infection
File Upload

Please attach in PDF patient Assessment Forms, Patient Results, Under 18 proforma's or any other relevant documentation for this referral.
Cancelof
Referee

First NameLast Name
Referee Email
example@example.com
Referee Contact Number
Please enter a valid phone number.Format: (00000) 000000.
Should be Empty: