Referral Form

These forms are only for tertiary referrals from other hospitals. We will not accept referrals from GPs using the online referral form below.

If you are a GP referring to the RNOH please use the NHS e-referral system, e-RS.

Required

Referring consultant’s details

Required
Required
Required
Required

Patient details

Required
Required
Required
Patient’s DOB: Required
Required

GP details

Is this patient registered with a GP in England, Scotland or N. Ireland?: Required

Before we discuss your patient’s case, we require the following information

Which hip is affected?: Required

Surgery details

Please give details of:

Required
Required

Please enter the patient’s oxford hip score

Blood cobalt

Blood cobalt date:

Blood chromium

Blood chromium date:

ESR

ESR date:

CRP

CRP date:

Painful hip arthroplasty/metal - previous blood test

Do you have previous blood tests?: Required

Blood cobalt

Blood chromium

ESR

CRP

Has the patient had a MARS MRI? Please include the date of the last one.
Has the patient had a hip aspiration? Please include the date of the last one:
If so, was the hip aspiration infected?
Has the patient had an ultrasound scan? Please include the date of the last one:

If you have any enquiries about this service or wish to provide outstanding test results, please contact the MDT coordinator on 020 8909 5279 or fax 020 8909 5277.

Declaration for MDT reports

  1. Our clinical advisory service is based upon the information presented to us by the referring doctor.
  2. We understand that it is our duty to help on the matters within our expertise and we will comply with that duty.
  3. We will do our best in preparing this report, to ensure that it is accurate and complete. We will mention all matters, which we regard as relevant to the opinions we express. All of the matters on which we express an opinion lie within our field of expertise.
  4. We will draw attention to all matters, of which we are aware, which might adversely effect our opinion.
  5. Wherever we have no personal knowledge, we will indicate the source of factual information.
  6. We will not include anything in this report, which has been suggested to us by anyone, without forming our own independent view of the matter.
  7. Where, in our view, there is a range of reasonable opinion, we will attempt to indicate the extent of that range in the report.
  8. At the time of sending the report, we will consider it to be complete and accurate. We will notify the referrer if, for any reason, we subsequently consider that the report requires any correction or qualification.