OCCUPATIONAL HEALTH ADVICE REQUEST

Practice: _____________________________________________________

Referred by: _________________________ Date referred: ___/___/___

PATIENT DETAILS

Name: _______________________________________________________

Address: ____________________________________________________

______________________________________________________________

Tel No: ______________________________ Date of Birth: ___/___/___

ASSISTANCE REQUIRED:

Reason for referral: __________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Appointment required Yes No

Information only Yes No

Permission to contact by telephone Yes No

Please ask the patient to take this form to reception to make an appointment or for the Occupational Health Adviser's information.

For Occupational Health Adviser's use only

If a patient has been made ill by work or if illness is preventing them from working please refer them to SOHAS.

We provide advice, health checks and specialist referral.

We can help patients

If you require any further information then please contact:

Sheffield Occupational Health Advisory Service

SOHAS

3rd Floor Queen's Building

55 Queen Street

Sheffield S1 2DX

Tel. No. 0114 275 5760

Fax No. 0114 249 1883

Email : sohas@sohas.co.uk

OCCUPATIONAL HEALTH ADVICE REQUEST

Practice: _____________________________________________________

Referred by: _________________________ Date referred: ___/___/___

PATIENT DETAILS

Name: _______________________________________________________

Address: ____________________________________________________

______________________________________________________________

Tel No: ______________________________ Date of Birth: ___/___/___

ASSISTANCE REQUIRED:

Reason for referral: __________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Appointment required Yes No

Information only Yes No

Permission to contact by telephone Yes No

Please ask the patient to take this form to reception to make an appointment or for the Occupational Health Adviser's information.

For Occupational Health Adviser's use only

If a patient has been made ill by work or if illness is preventing them from working please refer them to SOHAS.

We provide advice, health checks and specialist referral.

We can help patients

If you require any further information then please contact:

Sheffield Occupational Health Advisory Service

SOHAS

3rd Floor Queen's Building

55 Queen Street

Sheffield S1 2DX

Tel. No. 0114 275 5760

Fax No. 0114 249 1883

Email : sohas@sohas.co.uk

SOHAS Occupational Health Advice Request Form - Jan. 07