ScotSTAR Neonatal Elective Referral Form Transfer DetailsDate transfer required: DD slash MM slash YYYY Reason for transfer:Please SelectRepatriationSpecialist R/VMRISurgeryMRI Time: Hours : Minutes AM PM AM/PM *Baby will need a nurse escort from the unit to come with the transport team and stay with the baby during the MRI*Date of planned surgery: DD slash MM slash YYYY Referring Hospital & Department:Receiving Hospital & Department:Does baby have/had any known infections and/or barrier nursed:Please SelectYesNoKnown Infections:Has the mother or baby been an inpatient in a hospital outwith Scotland in the last year:Please SelectYesNoSpecify Location:Name of Referrer:Contact Number:Patient DetailsPatients Name:Patients CHI:Gestation at birth:Birth Weight (kg)Sex:Please SelectMaleFemaleCurrent gestation:Current Weight (kg)Brief History (including current stability):Current Clinical ConditionRespiratoryPlease SelectSVIALow Flow OxygenHFNCCPAPDuoPAPVentilatedModes & SettingsEnteral feeding at time of transfer:Please SelectNG/OGBottleBreast & NBMType of Milk:Frequency:Do we need a coolbox for maternal EBM: Yes No Cool box size:Small (up to 15 bottles)Large (over 15 bottles)IV infusions / drugs other than routine oral drugs: Yes No Infusions*IV infusions in 50ml syringes please*IV Access NIL PVC PICC / LL UVC Arterial Access Yes No Current phototherapy: Yes No Does a parent /carer wish to travel: Yes No TBC *They must be independent / fully discharged & fit to travel* Any social issues / Safeguarding: Yes No Enter informationAny other relevant details: Optional*A FULL MEDICAL & NURSING HANDOVER WILL BE REQUIRED TO BE GIVEN TO TRANSPORT WHEN THEY ARRIVE AT REFERRING UNIT* Please see referral process information: Elective transfer referral process – ScotSTAR Scottish Neonatal Transport Service Please print & complete: Pre transport checklist for referral units Contact transport team for any further information.ConfirmationEmail Enter Email Confirm Email CAPTCHA OptionalComments OptionalThis field is for validation purposes and should be left unchanged.
