<PracticeLetterhead>

REFERRAL FOR FALL PREVENTION	

Date: <TodaysDate>

Referral to:
<AdrDetails>

Patient’s Name: <PtFullName>
Date of Birth: <PtDoB>
Address: <PtAddress>
Contact number: <PtPhoneH> <PtPhoneMob>

Patient fall risk factors:
I have recently conducted a fall risk assessment for <PtFullName> and have identified the following factors contributing to her risk for falling:
•	 [PLEASE LIST FALL RISK FACTOR(S) HERE]
•	
•	 
•	

GP recommendations:
I am recommending [PLEASE LIST TAILORED MANAGEMENT HERE] and I would like your assistance in developing a management plan specific to fall prevention for <PtFullName>. 
I have attached the fall risk assessment that I have conducted for your reference.

Follow-up:
I would appreciate a summary of your recommendations or patient progress report being forwarded to me.  

The following patient information may be relevant for you to develop the management plan:

<PMHAll>
<FamilyHx>
<SocialHx>
<CurrentRx>

GP’s signature: ___________________________

<DrDetails>