Referral Forms

​​​​​​​​​​​​Referral forms - St Helens and Knowsley Teaching Hospitals NHS Trust

 

PLEASE NOTE ALL REFERRAL FORMS SHOULD BE PRINTED OFF AND HAND WRITTEN / TYPED, THEN FORWARDED IN THE USUAL WAY TO THE TRUST.

THE FORM CANNOT BE EMAILED AND CAN ONLY BE SUBMITTED BY POST

Please click the link below to view the relevant referral forms within each department.​​​

​Cancer Services: Suspected​​
Bone Cancer and Sarcoma
Breast Cancer
Children's Cancer
​Colorectal Cancer
Gynaecological Cancer
Haematological Cancer
​Head and Neck Cancer
​Lung Cancer
Skin Cancer
Upper GI Cancer
Urological Cancer

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​Cardio Respiratory
​ECG Referral Form 
​Spirometry Referral Form
​Echocardiogram
Cardiac Event
Ambulatory Monitoring​
​Rapid Access Chest Pain Clinic​​

Department of Medicine for Older People​
Movement Disorder Referral Form
Allen Day Unit Referral Form 
​Diabetes
Adult Diabetes Outpatient Referral Form
​Mersey Regional Burn & Plastic Surgery Unit:​​
Referral to Mersey Burn Unit Performa
Admission Referral Criteria
Admission Proforma
​Intensive Care Fluid Guideline
Necrotising Fasciitis​ Protocol
Adult Non-Complex Burns
Adult Complex Burns
Adult Referral Criteria Guidelines

 

​Neurophysiology ​​
​EMG Conduction Studies Referral Form

 

​​Palliative Care
​Specialist Palliative Care Services

 

​Radiology​​
​Imaging Request Form
MR Request Form
​PE Proforma​​

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​​Rheumatology​
Diagnosis and initial management of Giant Cell Arteritis
Early Inflammatory Arthritis Referral Form 

 

​​Sexual Health ​​
GU Medicine

 

Patients are eligible for free NHS treatment at St Helens and Knowsley Teaching hospitals NHS Trust if they are: Ordinarily resident in the UK or: Overseas visitors, but entitled to free NHS services under the National Health Service (Charges to Overseas Visitors) Regulations

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