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SECTION A: PATIENT INFORMATION
Patient Name
*
Patient Date of Birth
*
Month
/
Day
/
Year
Patient Address
*
Eircode
*
Patient Contact Number
*
Mobility Status
Please Select
Independent
Independent with Mobility
Wheelchair Dependent
Non-Weight Bearing
Indication for SIC
*
Relevant past medical history (including allergies)
*
Type of LoFric Catheter prescribed?
*
Please Select
Lofric Elle
Lofric Sense
Lofric Origo
Lofric Hydro-Kit
Lofric Primo
Type of tip
*
Please Select
Nelaton
Tiemann
Flexible Tip
Size (Ch) of Catheter prescribed
*
Length
*
Please Select
Standard
Female
Frequency of the SIC per day/week?
*
SECTION B: REFERRING CLINICIAN INFORMATION
Name of Urology Nurse
*
Hospital/Clinic Name
*
Email address of Nursing Department
*
Nursing Department Contact Number
GP Name
GP Telephone
Patient has undergone a Urology Nurse Review and a received prescription?
Please Select
Yes
No
comments
Patient consent obtained for referral to Fannin for Education
*
Please Select
Yes
No
Has the patient consented to Fannin contacting them directly
Please Select
Yes
No
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