Post COVID Syndrome MDT Assessment Referral Form

To request a referral for a Post COVID Syndrome MDT assessment, please submit this form.

Post COVID Syndrome MDT Assessment Referral

Post COVID Syndrome MDT Assessment Referral

Section

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:
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