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​​​​​​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 forms cannot be emailed and can only be submitted by post.

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

Referral Forms​

Cardio Respiratory

​ECG Referral Form

​Spirometry Referral Form​

​Echocardiogram Referral Form

​Cardiac Event

​Rapid Access Chest Pain Clinic​​

​Ambulatory Monitoring Referral Form

​Department of Medicine for Older People​

​Movement Disorder Referral Form

​Allen Day Unit Referral Form


​Adult Diabetes Outpatient Referral Form

​Mersey Regional Burn & Plastic Surgery Unit

​Referral to Mersey Burn Unit Proforma

​Admission Referral Criteria

​Admission Proforma

​Intensive Care Fluid Guideline

​Necrotising Fasciitis​ Protocol​

​Adult Non-Complex Burns

​Adult Complex Burns

​Adult Referral Criteria Guidelines​

​Neurophysiology ​

Please note: Referral forms only accepted via ERS

EMG Conduction Studies Referral Form​

​​Palliative Care

​Specialist Palliative Care Services​


​Imaging Request Form

​MR Request Form

​PE Proforma​​​


Diagnosis and initial management of Giant Cell Arteritis

Early Inflammatory Arthritis Referral Form

​​Sexual Health ​​

​GU Medicine​


Feedback Form