Immunisations professional's referral form

Your information

If you would like to find out what happens to personal information held about you, please read the your personal information section on our Legal page. You can also read our privacy policy for more information.

GPs or other health professionals can refer children to us using the professional referral form below.

Are you a ...*
We work hard to make sure your information is safe. As personal email accounts are not encrypted, there’s a very small risk that the emails sent between us could be opened and read by someone else or ‘hacked’. If you’re worried about this, we can support you to make your email communication with us extra secure. Please call us on 0300 123 5205 or email kchft.cyp-immunisationteam@nhs.net and we can help you set up a secure email communication.
Child/young person details
Forename*
Surname*
Date of birth*
Gender*
Ethnicity*
NHS number (if known)
Address*
Street Address Address Line 2 Town County Postcode
Mobile number
Referrals cannot be made without the agreement of the parent/carer and/or young person. Confidentiality is respected in accordance with the Data Protection Act. We also have a duty to refer any child who may be in need of protection to Social Services.
Consent to referral obtained from child/young person?*
- Yes
- No
If no, why?
Does your child attend school?*
- Yes
- No
School*
If other school, please specify
Year group

(if applicable)
Referrer details
Your name*
Is your address same as the child/young person?*
- Yes
- No
Your address*
Street Address Address Line 2 City County Postcode
Your phone number*
Your email*
Do you give consent to receiving text reminders for appointments as appropriate?
- Yes
- No
Your relationship to the child/young person?
Do you have parental responsibility?
- Yes
- No
Reason for referral
Reason for referral*
- Identified missed vaccination
- Incomplete/Unknown vaccination history
Please provide details*
Attachment(s)
Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.
Hidden
Professional referral
Confidentiality is respected in accordance with the Data Protection Act. We also have a duty to refer any child who may be in need of protection to Social Services.
Parent/carer consent obtained*
- Yes
- No
- Not required - young person assessed as Gillick competent and gives self consent (please evidence)
Confirmed parent/carer have parental responsibility*
- Yes
- No
Has child/young person consented for parents/carers to be informed of this referral?*
- Yes
- No
Do not contact parent/carer without prior discussion with young person.
Why has the child/young person not given consent?*
How this information was gained?*
Referral details
We work hard to make sure client information is safe. Some email accounts belonging to practitioners working outside of the NHS may not be encrypted. We will therefore send information by a secure method called Egress, you will need to register for an account in order to open any correspondence we send you that contains sensitive or identifiable information. You will be asked to register an Egress account so you can read and respond to emails securely, if we send an email regarding a referral.
Child/young person details
Forename*
Surname*
Date of birth*
Ethnicity*
Gender*
NHS number
Address*
Street Address Address Line 2 Town County Postcode
Phone

(if applicable)
Does the child/young person attend school?*
- Yes
- No
School*
If other school, please specify
Year group

(if applicable)
Child/young person GP name*
GP address*
Street Address Address Line 2 City County Postcode
GP phone*
Parent/carer details
Parent/carer name*
Is their address the same as the child/young person?*
- Yes
- No
Address*
Street Address Address Line 2 City County Postcode
Phone*
Does parent/carer consent to receiving text reminders for appointments as appropriate?
- Yes
- No
Reason for referral
Reason for referral*
- Identified missed vaccination
- Incomplete/Unknown vaccination history
Please provide details*
Please evidence what reasonable attempts have been made to engage this child in the offered vaccination programme.
Referrer details
Name of referrer*
Referrers role*
Other role*
Designation*
Date of referral*
DD slash MM slash YYYY
Address*
Street Address Address Line 2 City County Postcode
Phone number*
Email*
Attachment(s)
If you have any additional information please add any related documents here.
Drop files here or

Accepted file types: pdf, docx, jpg, jpeg, png, xlsx, pptx, Max. file size: 50 MB.

Immunisations professional’s referral form

Your information

Child/young person details

Referrer details

Reason for referral

Professional referral

Referral details

Child/young person details

Parent/carer details

Reason for referral

Referrer details