Peristeen Training Referral Form

Referrer's Details

Referrer Name

Date of Referral

Contact Telephone

Email Address

Hospital/Community Base

Request for Peristeen Training

Peristeen Plus Balloon Catheter

Peristeen Plus Cone

Patient Information

First Name

Surname

DOB

Contact Telephone

NHS Number

Address

Postcode

GP Details

Consultant

Patient Condition

Patient condition if other

Previous bowel history / investigations / surgery

Any previous bowel management intervention

Relevant Medical / Surgical History

Current Medication

Has a DRE (Digital Rectal Examination) been undertaken?

Yes

No

Date of DRE

Please comment on any findings on DRE? or reason for no DRE being undertaken

Has this pt any cognitive impairment that would impede on the pts ability to provide informed consent

Yes

no

Have you assessed and excluded any contraindications? as per TAI assessment

Yes

No

_{Read the contraindications}

If relevant, please provide any additional information in relation to medical history

Additional information in relation to social / home environment

Any additional information in relation to Peristeen bowel management routine

Patient consented to referral and follow up by a Coloplast Nurse and to receive initial supplies from Coloplast Charter?

Yes

No

Additional notes

Benefits of the Coloplast® Professional Educational platform

Peristeen referral form for training

Referrer's Details

Referrer's Details

Patient Information

Patient Information

To speak to us or for more information

Get full access with a free account

Benefits of the Coloplast® Professional Educational platform

Peristeen referral form for training

Referrer's Details

Referrer's Details

Patient Information

Patient Information

To speak to us or for more information