Tissue Viability Referral Form

To download/print a copy of this form, please click here.

Please note: All fields are mandatory and must be completed.

Resident's First Name

Resident's Last Name

DOB

Name of nursing home

Unit (if applicable)

County

Medications (Steroids, antibiotics, immunosuppressant)

Medical History

Surgical History

Allergies

Infection Status

Nutritional & Hydration Status (contact dietitian if assistance is required)

Continence Status

Mobility Status

Location of Wound

Wound Measurements

Exudate Volume (scant, low, moderate, and high)

Exudate description (serous, sanguious, seriosanguinous, purulent)

Odour (none, slight on removal of dressing, offensive)

Dressings in use (Primary & Secondary)

Pain YesNo

Is this resident under the care of a Vascular Consultant YesNo

If yes please provide the following (mandatory)

Vascular Consultant Name

Vascular Consultant Hopital

Referrer's Name

Referrer's Job Title

Email Address

Date

Telephone No.

Photo Attachment (please ensure photos are clear and in colour)

Consent

Please select as appropriate: The resident has consented to this referralThe referral has been made in the resident's best interests

Note: if you don’t receive a confirmation email please contact your Nualtra account manager

Referring nurse must sign referral with his/her name- any referrals signed as ‘CNM Nurse on duty’/‘Staff Nurse on Duty’ or left blank will not be accepted

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