MSK CAS referral Form

Please refer patients presenting with the following to the relevant secondary care clinics and not to MSK CAS: 
•	Patients under 16
•	Fractures
•	Red flag symptoms 
•	Patients who require and want surgery
•	Patients with active inflammatory disease 

Please include any recent MRI reports 

Title	Forename	Surname	
Date of Birth	 		
Nhs Number	 		

Please answer all questions: 

Does the patient require an advocate?	Yes 	No 	
If so please specify the language 	 	
Does the patient require hospital transport? 	Yes 	No 	
Presenting condition (brief description) 	
Past Medical history (please cut and paste) 	
Drug History (please cut and paste)