Stoma Care Patient Referral Form


Patient Name:

Date of birth:

Hospital/Stoma Nurse:

What was the reason for your stoma being created?:

Appliances and accessories currently used:

Do you suffer with any allergies?

Please detail the reason you have requested stoma care advice:

Image upload:

I agree to this form being passed to a Salts Medilink Clinical Nurse Specialist in Stoma Care to review and provide telephone advice