SOUTHWARK & LAMBETH MEMORY SERVICE (SLMS)
The Gatehouse, Ann Moss Way, London, SE16 2TH
Tel. No: 0203 228 0570; Fax No: 0203 228 0571
REFERRAL FORM FOR ASSESSMENT AND TREATMENT
PATIENT:
Surname: / First name: / Title:Address: / Postcode:
Telephone no: / NHS number: / DoB:
Ethnicity: / Main spoken language: / Interpreter required?
Yes / No
Lives alone? / Lives with? / Sex / Marital status:
Yes / No / Male / Female
CARER / NEXT OF KIN CONTACT DETAILS:
Please give details of anyone who will need to remind / assist the patient to attend appointments
Name: / Relationship:Address: / Tel no:
History of presenting memory complaint: (duration / onset / symptoms)
Degree of cognitive impairment: / MILD / MODERATE / SEVERE
Medical history:
Current medication:
Risk factors identified:
Please tell us the best way to assess this patient:
Is able to attend clinic (unfortunately we do not provide transport)
Would require a home visit
Date of referral: / Requesting GP name: / Practice name:
Patient aware of referral? / Practice address:
Yes / No
Carer aware of referral? / Practice phone no: / Practice fax no:
Yes / No
SOUTHWARK & LAMBETH MEMORY SERVICE
Assessment and Treatment
To avoid delay, the following must be included with the referral:
Dementia screen blood tests (MUST be recent, i.e. within 3 months of referral date)
FBCRandom glucose
TFTs
LFT incl. GGT, B12 & Folate
U&E
MSU / ESR
Ca²+
CRP
Lipids
Syphilis / HIV screen
Please also attach a recent ECG if your patient has had one in the last 6 months
Bloods enclosed with Referral? / Yes / No / To be done? / Yes / NoPhysical examination carried out / Yes / No / Date:
In keeping with infection control requirements, please tell us if any of the following conditions relate to this patient:
C difficileMRSA
diarrhoea / urinary catheterisation
TB
None are applicable
Before returning this form to Southwark & Lambeth Memory Service, please ensure your patient meets our referral criteria:
Referral criteria
ü Working age adults and older adults
ü Subjective memory problems
ü Change in everyday function over period > 6 months
ü Carer’s report of change in client
ü No previous or definitive diagnosis of dementia
The clinic will not see any cases where urgent attention is needed
e.g.
Behavioural problem
Suicidal ideation
Psychotic behaviour
Crisis situation from carer’s perspective
These cases should be referred directly to older adults’ CMHTs or ELMS as indicated.
Please ensure that all sections of referral form are completed and attach any additional information to this form. Thank you for your co-operation.
Please send your referral to: / POST: Southwark & Lambeth Memory Service, The Gatehouse, Ann Moss Way, London SE16 2THFAX: 0203 228 0571
SLMS Referral template: Jan 2014