Adult Fracture Clinic Referral · Virtual Fracture Clinic

This form is to be used for adult general fractures and soft tissue injuries. Any injuries to the wrist or hand should be referred on a different referral form.

We DO NOT accept referrals for:

Spine injuries including soft tissue/whiplash injuries
Children under the age of 16
Open fractures, these should always be referred to the Orthopaedic on-call team
Dislocated total hip replacements

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

Referral

PATIENT

Hospital ID

Gender

First Name

Last Name

Date of Birth

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

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