Adult Fracture Clinic Referral · Virtual Fracture Clinic

This form is to be used for adult general fractures and soft tissue injuries suitable for the Virtual Fracture Clinic inline with the Acute A&E Orthopaedic Guidelines

If your referral relates to a Hand and Wrist Injury please complete the Virtual Hand and Wrist Fracture Clinic referral form on bamboo

Please note, we DO not accept referrals for:

Spinal injuries including soft tissue/whiplash injuries
Children under 16 – refer to Paediatric Virtual Fracture Clinic via Panda
Open fractures - refer to orthopaedic registrar on-call
Dislocated total hip replacements- refer to orthopaedic registrar on-call
Post-operative conditions
Wounds or foreign bodies – refer to orthopaedic registrar on-call

If the referral does not fit our criteria it may be declined and returned to you via email

Further guidance on the Orthopaedic pathways can be found by clicking here.

Referral

PATIENT

Hospital ID

Gender

First Name

Last Name

Date of Birth

Run Referral to Case Flow

Date Flow Ran

CONTACT CONSENT

Agree for contact by eMail

Agree for contact by telephone

Agree for messages to be left by voicemail

Mobile Phone

CLINICAL DETAILS

Date of Assessment

Date of Injury

Mechanism of Injury and Assessment Findings

Region

Left or Right

Diagnosis

Diagnosis (Other) / Additional Injuries

Care Plan URL

TRiP(cast) score (points)

VTE Prescribed

Comments (dose, duration, any other information relevant to prescription)

Please print this off and give it to your patient

Physical Treatment

Boot

Sling

Knee Brace

Humeral Brace

Crutches

REFERRED BY

Referring Organisation

Referring Clinician's Name

Referring Clinician's Job Title

Referral Location

Original Hospital Name or GP Surgery

Clinician Email Address