Wound care referral

To make your wound care / leg or foot ulcer referral, please complete all the applicable fields in the form below.

Once your referral is in our system, we will contact the patient GP’s to approve the appointment and any transport requirements. Patients will be seen according to the degree of urgency.

Wound care referral form

Referral date*
Patient's full name*
Title*
Gender*
Date of birth*
NHS number*
Address*
Street Address Address Line 2 City Post code
Phone number (best contact)*
Mobile number
Email
Ethnicity*
Translation needed?*
- Yes
- No
Language
Referral made by?*
Job title*
Phone number*
Email*
District Nurse or Practice Nurse (name / team)*
District Nurse or Practice Nurse email*
District Nurse or Practice Nurse phone*
GP name*
GP practice*
GP address*
Street Address Address Line 2 City Post code
GP phone number*
GP email*
Clinical Commissioning Group (CCG)*
Additional referral information eg transport and access information
Wound type/problem (including location, grade, ABPI as appropriate)*
Relevant history to the wound
Current wound management and medication, please state if none*
Any other comments
Allergies*
- Yes
- No
Any relevant comments about allergies
Other medical conditions eg. diabetes etc
Upload your patient's EMIS history
Drop files here or

Accepted file types: pdf, doc, Max. file size: 50 MB, Max. files: 20.
You can upload your EMIS files here or email as per the details below.
Confirm EMIS print out of history emailed to acceleratecic.accelerate@nhs.net OR uploaded above*
- Confirm
If you want to provide photographs of a wound or limb, email them securely to acceleratecic.accelerate@nhs.net giving the name of the patient and date of birth.

Wound care referral

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Wound care referral form

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Wound care referral

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Wound care referral form

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