G.P's, Stoma Nurses & Clinicians

Patients Details:

Name*

Date of Birth*

NHS Number*

Full address*

Postcode*

Telephone*

Mobile

GP*

GP Practice Name & Address*

Clinical Condition*

(Use this area to inform U-drain limited about any unusual or problematic behaviour linked to the patient or their family/property location)

Additional Information*

CCG & H/C/P Details:

Health Care Professional Name*

Clinical title (please tick one)*

G.P. Stoma nurse Other

Telephone*

Email*

CCG or Healthcare Organisation Name*

CCG or Healthcare Organisation Code*

By completing and sending this Pro-forma you are hereby authorising the Initial contact between U-drain Limited & the above named Patient, the subsequent Installation of the U-drain System/Equipment and the prescribing of the U-drain consumable pack on the Drug Tariff part IXB. Once this Pro-forma has been received by U-drain Limited, we agree to contact the Patient within 72 hours to arrange convenient date for site visit, installation & patient training.

(*) Mandatory field


		0161 941 1969