Paediatric Nutrition and Dietetics OUTPATIENT clinic Referral Form
Paediatric Nutrition and Dietetics OUTPATIENT clinic Referral Form (0-16 years)
Prior to completing this form, please read the referral criteria from page 4 onwards to check whether the referral will be accepted. Please call us on 01296 831690 or email the department on
firstname.lastname@example.org if you require further information.
Please ensure you fill in all pages of this form.
Please note – this is a community service; we aim to triage referrals within 21 days of receipt. We aim to see all patients within 18 weeks (certain referrals will be prioritised based on clinical judgement).
For the prescription of Cow’s milk protein allergy(CMPA) formula, please refer to the CMPA formula guidelines for initial management in primary care.
Please send completed referrals by EMAIL to: Paediatric referrals: email@example.com Tel: 01296 831 690