Clinisupplies | Aquaflush Nursing Service Referral

Appointment Option *

Referrer Details:

First Name *

Last Name *

Phone

Email *

Location/Department

Patient Details:

Title *

First Name *

Last Name *

NHS Number *

Phone *

Email

Date of Birth *

Day

Month

Year

The patient consents to being contacted by a member of the AVNS teamYesNo

Patient Address:

House/ flat no *

Street *

City/Town *

County *

Postcode *

GP Details:

Surgery Name *

Street *

City/Town *

County *

Postcode *

Medical Conditions

Please tick if your patient has any of the conditions below

DRE date (required for adults only) *

Day

Month

Year

Contraindication for use

Please click on this link to review contraindications of TAI usage Click here

Please confirm your patient does not have any of the contraindications.

Comments

Use under guidance of Consultant/ Specialist

Click here if none of the below apply.

Severe autonomic dysreflexiaLong term corticosteroid therapyBleeding diathesis/anticoagulant therapyUse of rectal medications

Additional Information

Patient Weight (Kg) *

Maximum Water Limit

Any known learning needs *

Preferred product and cone choice

Irrigation System Choice

Cone Choice

Volume

Comments

Bladder

Bowel

Accessories

Bandages & Garments

Aquaflush Nursing Service Referral