Surname	     	Date of Birth
(format: dd/mm/yyyy)	     	
Forename(s)	     	Title 
(click here for option box)		
Address	     	Gender
(click here for option box)		
Post Code	     	NHS No (if known)	     	
Telephone No	     	Mobile No	     	

Registered GP	     	Surgery	     	
Practice Code	J     			
Consultant 
(if appropriate)	     			

Is the patient physically able to attend hospital appointments?	          Yes   	         No   	

Reason for referral		

     	
Relevant medical/surgical history	

     	

Is patient aware of referral?		Yes    			No    			Unknown		
Is GP aware of referral?		Yes    			No    			Unknown		
Are any other services involved?
(please tick appropriate box/boxes)  	District Nurse	      	Home Care  	      	OT	    	
Social Worker	      	Physio			CPN		None	
Other (please specify)	     	

Referral raised by:	     	Date:
(format: dd/mm/yyyy)	     	
Signature:		Relationship	     	
Address:	     	Telephone No:	     	
If using SystmOne, please send this form via electronic referral, selecting the following Task Recipient:  
Bladder and bowel east (not west)	
If not using SystmOne, please send this form to:  
bladderandbowelportsmouth@solent.nhs.uk or by post to St Marys Community Campus, First Floor DSU, Milton Road Portsmouth, PO3 6AD 	
For further advice, please contact us on: 
0300 123 3386