Skip to content ↓

School Nurse Referral Form

Swan House

Gloucester Centre

Peterborough

PE2 7JU

01733 74 68 22

Cpm-tr.peterobroughschoolnurses@nhs.net

School Referral To School Nurse

Confidential Request

Child full name

 

DOB

 

Address:

 

Telephone Number

 

School

 

Parents/ Carers Name

 

GP

 

         

 

Reason for Referral…………………………………………………………………………………. ……………………………………………………………………………………………………………………………………………………………………………………………………………………...

How Long Has Child had  the problem? …………………………………………………………

Referred By

Name………………………………………………………………………………………………...

Designation / Role..…………………………………………………………………………………

Contact number …………………………………………………………………………………….

Please explain to the parents why you have made the referral and obtain consent for the referral by asking the parent to sign this form

Parent / carers signature

 

Parent / carers Name

 

Date

 

 

Contact number