ScotSTAR Neonatal Elective Referral Form

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Transfer Details

Date transfer required::

Date of Referral:

Appointment Time (if applicable):

Referring Hospital:

Department:

Receiving Hospital:

Department:

Name of Referrer:

Contact Number:

Reason for Transfer (e.g. repatriation, elective surgery etc):

Patient Details

Name:

CHI:

Gestation at birth:

Birth Weight:

Sex:

Current gestation:

Current Weight:

Brief History:

Current Clinical Condition

Respiratory (mode of support and settings):

Expected feeds/fluids at time of transfer: :

IV infusions / drugs other than routine oral drugs:

IV Access:

Arterial Access:

Other relevant details:

Current Phototherapy:

Cool bag for EBM:

Social Issues relevant to Transport:

Parents / Carer wishing to travel:

Infectious Disease Risk

Has mother or baby been colonised with MRSA at any time:
YesNo

Has the mother or baby been an inpatient in a hospital outwith Scotland in the last year (If Yes, please specify location):
YesNo

Is the referring unit currently experiencing infectious outbreak/undertaking enhanced infection precautions (If Yes, please specify reason):

YesNo

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