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Clinical Nutrition and Dietetics – Oncology Dietetic Team referral form

Your information

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Inclusion criteria

Patient is 18 or over and currently receiving Oncology treatment in East Kent. The Oncology Dietetic Team provide telephone and video consultations and / or face to face consultations at Kent and Canterbury Hospital, William Harvey Hospital and Queen Elizabeth the Queen Mothers hospital whilst patients are attending for treatment.

Clinical Nutrition and Dietetics - Oncology Dietetic Team referral form

I am a health care professional /registered care home manager(Required)
You have to be a healthcare professional or registered care home manager to complete this referral.
Select date DD slash MM slash YYYY
Is this referral urgent, for example, high risk, patient safety concerns or prevention of avoidable hospital admission?(Required)

Reason for referral

To enable us to process your referral appropriately please complete this form as fully as possible. Referrals with insufficient information will be returned to the sender for revision.

Patient details

Name(Required)
Date of birth(Required)
Address(Required)

Additional contacts

GP
Name
Phone
Organisation
 
Next of kin
Name
Phone
Relationship to patient
 

Cancer

Cancer

Medical history

Drop files here or
Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 10 MB.
    Please include any Oral Nutritional Supplements (ONS), if already prescribed.

    Patient anthropometrics
    Select date DD slash MM slash YYYY

    Accessing the service

    Does the person need any communication support to access this service?(Required)
    Will the person need an interpreter?

    Social situation

    Social situation
    Any known risks?

    Patient consent

    Is the patient aware of and has consented to this referral?(Required)

    Referred by

    Referrer(Required)
    Name
    Job title
    Organisation
    Phone
    Email

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