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Please tell us the reason and expectations for referral and any significant medical factors.
Please explain which of the following eligibility criteria the patient meets. The patient should have an associated cognitive behavioural or psychiatric disorder.
Please note we do not routinely see patients whose primary problem is:
Please include details of the following:
It would also be helpful if you could include information such as:
For new referrals (for investigation and assessment), please could you kindly confirm the bloods listed below have been completed recently and indicate which memory screening tools have been used, along with any additional information (e.g. scores).
Bloods
Memory screening
We are grateful for any additional information on potential risks or concerns regarding this referral such as:
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