Referral form
Referrals for Flora Cultura are for service users with mild to moderate conditions. We work with a maximum staff to service user ratio of 1:8 and therefore we do not have the capacity to work with people with severe conditions. Our site is currently not accessible for wheelchair users but this is something we aim to change. If you would like to discuss a referral then please call 07585706840
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Name of your organisation/department *
Date of referral *
MM
/
DD
/
YYYY
Referrer's name and job title *
Referrer's email address and phone number *
Service user's name *
Service user's date of birth    (dd/mm/yyyy) *
Service user's address (only used for contact purposes if they do not respond to phone calls/txt, or email) *
Preferred contact details (phone number/e-mail). If the contact is a family member or carer please include their name and relationship. *
Service user's condition/s    (diagnosis + impairment code if known) *
Reason for referral to Flora Cultura *
Consent - Is the service user aware of the referral? *
Service user's health conditions affecting first aid treatment *
Required
Has the service user got any allergies that require them to carry an Epipen?        (Yes + list, No or Unknown) *
Any extra relevant information    (please include any known triggers)
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