These pro-formas are for referrals to Gloucestershire Hospitals Trust only.

 

• 2 week rule • Breast Surgery (inc 2ww) • Hearing Aid • Gynaecology • Cardiac Physiology • Renal • Orthopaedics • Rheumatology • General Information

2 Week Rule Referral Forms

If practices refer patients under the 2 week rule to other hospital trusts, please email and we will request templates from the appropriate trust. 

All 2 week rule referrals must include the appropriate pro-forma as an attachment. The pro-forma contains the appropriate clinical information, reason for referral (letter text) and a section for basic patient information (name, date of birth, NHS number and Choose and Book UBRN). This should be sent together with the practice's standard referral letter, which will contain full patient demographic information, practice details and items from the patient's medical reord if this has been set up. As all of this information can be automatically populated from the clinical system, it means that it will not have to be re-typed on the 2 week rule pro-forma. Both documents must be attached at the same time. 

Please click on the browser 'Refresh' button before downloading any of the forms to ensure that the links are to the most recent versions. 

It is recommended that these pro-formas can be downloaded and saved in an appropriate folder on your clinical server so that they can be used by all users within the practice. 

• 2WW Suspected Brain Tumour Referral Form - Generic  
• 2WW Suspected Colorectal Cancer Referral Form - Generic  
• 2WW Suspected Gynaecological Cancer Referral Form - Generic 
• 2WW Haematology Referral Form - Generic 
• 2WW Head and Neck Cancer Referral Form - Generic 
• 2WW Suspected Lung Cancer Referral Form - Generic 
• 2WW Suspected Sarcoma Referral Form - Generic 
• 2WW Skin Cancer Referral Form - Generic 
• 2WW Suspected Upper GI Cancer Referral Form - Generic 
• 2WW Suspected Urological Cancer Referral Form - Generic 
• 2WW RACP Referral Form - Generic  
• Rapid Access Chest Pain Service - Guidelines

Breast Surgery

• Breast Surgery Rerferral Form (including 2 week rule)

Direct Access Hearing Aid Proformas

• Direct Access Hearing Aid 4 Week Pathway Only Referral Form 
• Direct Access FIRST HEARING AID ONLY Proforma
• AQP Audiology Proforma - Hereford & Worcester patients only

Gynaecology Pilot Services proforma

• Continence Proforma - GP Pilot
• Gloucestershire Urogynaecology Continence Service  
• Direct Access Hysteroscopy Checklist  
• Direct Access Outpatient Hysteroscopy - Patient Letter

Cardiac Physiology Support Documents

• Gloucestershire CHD Network Palpitations Pathway  
• Referral Form

Renal Service Support Documents

• Indications for Referral to the Renal Service 
• Renal Referral Flow Charts

Orthopaedics

From 24th October 2011 all referrals to Hip/Knee and Spinal services should be made using one of the templates below.

•   Orthopaedic Referral Form
•   Hip / Knee 
•   Spinal

Pain Scores

Further information about the Pain, PHQ9 and GAD7 scores is available below:

•  PHQ9
  
•  GAD7
•  Numerical rating score of pain

Rheumatology

• Early Inflammatory Arthritis

General Information

• Full Process 
• Process Summary  
• Patient Information Slip