DA Referral form March 2017 .pdf
Original filename: DA Referral form March 2017.pdf
Title: Alzheimer's Society Report Template
Author: Alzheimer's Society
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County Durham Dementia Advisor Service
Confidential Referral Form
Chester le Street
Co Durham DH2 2DW
Tel: 0191 389 0400, Fax No: 0191 388 5905
Referrer Details (or use practice stamp):
Organisation and address:
Details of the person being referred:
☐Male ☐Female ☐Transgender
Date of birth:
Is the person aware of the referral?
Diagnosis of dementia?
Date of Diagnosis:
Details of Main Carer / Contact:
Any other relevant info.
Has the person given consent for referral?
☐Yes ☐ No
Other Health Issues, e.g. Stroke, Parkinson’s Disease?
Any known communication issues?
Any known risks?
Reason for Referral:
Please return to the Alzheimer’s Society, South Approach, Bullion Lane, Chester le Street, Co. Durham DH2 2DW,
Fax: 0191 3885905 or Email: firstname.lastname@example.org. Please insert the phrase alzecureemail! into
the title or body of your email to ensure it is delivered by secure email.
(Referral Form Version 7, March 2017)
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