Appointment Date: . Patient No./NHS No: .
Surname: .. Forename: .
Address .
. Post Code:
Date of birth: Date of death: (If applicable)
Gender: Male / Female District Code: .
Occupation: ..
Next of kin: .. Tel No: .
Ethnic Origin: (Please enter relevant code)
A White British
B White Irish
C Other White background
D Mixed White & Black Caribbean
E Mixed White & Black African
F Mixed White & Asian
G Oher mixed
H Indian or British Indian
J Pakistani or British Pakistani
K Bangladeshi or British Bangladeshi
L Other Asian or Asian British background
M Black or Black British Caribbean
N Black or Black British African
P Other Black or Black British background
R Chinese
S Other Ethnic Group
Z Not stated Z Not stated
Amputation date: Referral date: . Referral received:
Referring Hospital: Consultant Surgeon: .
GP Name & Address: ..
.. Tel No: ..
Category of Amputation: New Revision Transfer In
Amputation Level: Left Right
09 Hemipelvectomy 10. Hip Disarticulation. 11. Transfemoral 12. Knee Disarticulation
13. Transtibial 14 Ankle Disarticulation 15. Partial Foot 16. Digit
Congenital Limb Deficiency Please complete supplementary sheet.
Present Whereabouts: Home NH Hospital
Transport Requirements: Ambulance Own Transport