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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 Self-Intermittent Catheterisation
*
Size of Catheter Prescribed
Charriere Size (CH) of Catheter prescribed
Type of Tip
*
Please Select
Nelaton
Tiemann
Flexible Tip
Standard or Female Length
Please Select
Standard
Female
Please details any relevant patient history?
SECTION B: REFERRING CLINICIAN INFORMATION
Name of Urology Nurse
*
Hospital/Clinic Name
Email
*
Department Contact Number
Type of Catheter prescribed?
*
LoFric Elle
LoFric Sense
LoFric Origo
LoFric Hydro-Kit
LoFric Primo
What is the Frequency of the SIC for the patient?
Patient has undergone a Urology Nurse Review and a received prescription?
Please Select
Yes
No
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
Submit