7th November 2019


All external referrals to PICU must have the data below submitted. This will be sent to the data manager and Consultants; please complete accurately and with detail where possible

If you do not have a decision / outcome at point of submitting this form, please submit the outcome ASAP with this form (essential!): www.GeorgesPICU.org.uk/decision

*This form is not an emergency referral process. It is for data capture. No immediate response should be expected.

Main Referral Data Form:

Please enter your email, so we can follow up with you.
Include even if estimated
Not transport team, but rather where the patient currently is, e.g. DGH General Paediatrics, etc.