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Post COVID syndrome MDT assessment referral

Post COVID Syndrome MDT Assessment Referral
Required fields are labelled
Who are you completing this form for?
For example, on behalf of a child or dependent
What is your name?
What is your date of birth?
For example, 31 3 1980
What is your sex?
As recorded on your medical record
The one used to register with your GP
Anyone else with access to your email account may see responses sent to you

Mobility

Brief description of initial symptoms

Please select the relevant symptom(s):

Previous Management

(Please provide copies of all relevant information detailing care received, at the bottom of this form)

Please select the relevant option(s):
Did the patient require oxygen?
Does the patient still require oxygen?

Reasons for Referral

Please indicate reason(s) for referral:

Were any of the symptoms above present prior to their COVID illness?
Is the patient under the care of any other services post COVID-19?
Please provide copies of all relevant information detailing care received:

Do not upload sensitive photographs of genitalia, bottoms (anus), breasts or minors without asking a healthcare professional first. Your uploads may be stored on your health record.