Neuro Skull Base MDT Referral Form

The Skull Base MDT is held on ? mornings. Urgent opinions can be sought from the on-call team at other times.

If there are issues with this electronic form, paper-based referrals can still be made using the referral form emailed to sth.SkullBaseMDTReferrals@nhs.net.

This referral form is currently under development. DO NOT USE for live referrals yet.

– Referrer Information

Referring Consultant (Required)

Consultant's Email Address (nhs.net emails only) (Required)

Referring Speciality (Required)

Hospital (Required)

Referrer's Name (Required)

Referrer's Email Address (nhs.net emails only) (Required)

Referrer's Contact Phone Number for Referral Queries (Required)

Email Address for MDT Outcome (only provide a single, valid nhs.net email address) (Required)

+ Patient Details

Patient Name (Required)

Patient Date of Birth (Required)

NHS Number

Gender (Required)

Current Inpatient

Inpatient Location

Patient's Home Address (Required)

+ Pathology

Question To MDT (Required) (maximum 500 characters)

Background Information (Required) (maximum 500 characters)

+ Imaging

Imaging Hospital

MRI Performed (Required)

MRI Date

Please Confirm the MRI Has Been Transferred to STH

CT Performed (Required)

CT Date

Please Confirm the CT Has Been Sent to STH PACS

+ Other

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