Digital Support Service / Refer a Patient

Your details - Third party referrer

Referrer's name

Service/Organisation (e.g. your Hospital / Trust / GP Practice / Organisation / Service name)

Your role or your relationship to the person you are referring (select one)

- Select -GPDoctorNurseOther medical professionalSocial prescriberHealth coachCommunity ConnectorSocial WorkerOther support workerFamily memberFriendOther (not listed)

Referrer's email

Referrer's telephone number

Their details - The person being referred

Full name of the person being referred

Title

What would the person you are referring like us to call them? (e.g. 'Mrs Brown' or by their first name if they prefer)

How should we contact the person you are referring?

Telephone

Email

SMS (Text message)

WhatsApp

Other (e.g. carer, famly member. friend etc.)

If other, please provide details here

Main telephone number (mobile or landline)

Their email address (if they have one)

Their address

Their address

Their postcode

Can they communicate in English?

Yes

No

If not, what is their first language?

Do they have any medical or health issues, including mobility, mental health or cognitive issues that we should know about?

Yes

No

If 'Yes', please provide more details here

Support needed

Do they currently have an internet enabled device? (i.e. Smartphone, Tablet, Computer)

Yes

No

Please give details if known (e.g. iPhone or Android smartphone, Windows or Mac computer)

What support and equipment needs do they have? (Please select all applicable options)

In need of a loaned device and support to use it

Help connecting to GP video consultation/appointment (GP - accuRx)

Help with eConsult Form for GP consultation/appointment

Help with online registration for GP patient services (e.g. PatientAccess, MyGP, NHS app)

Help with other GP online services (MED3, Physio, etc.)

Help connecting to Hospital video consultation appointment (AttendAnywhere)

Help to access Zoom or Microsoft Teams for appointments

If the person you are referring is in need of a device and support to use it, please indicate main intended use and required duration for loan device below.

Main intended use (e.g. GP/Hospital appointments, regular meetings, therapy sessions etc.)

Duration for loan device

Does the person you are referring have any other health related digital activities or system needs? Please give details

Demographics

Their date of birth

What is their gender?

Male

Female

Consent

Is the person you are referring aware of this referral and have you gained their consent?

Yes

No

We will store the information on this form securely. In order to provide support we may share it with North Central London CCG and Public Voice.

Tick here if they are happy for us to share this information in order to provide them with the best support.

Tick here if they are happy for someone from our team to contact them.

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