0161 941 1969

 



G.P's, Stoma Nurses & Clinicians

Patients Details:

Name*
Date of Birth*
NHS Number*
Full address*
Postcode*
Telephone*
Mobile
Email
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
 
 


Installation Instructions
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User Guide
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Water, A Primary Need
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Automated Peritoneal Dialysis
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