First Seizure Clinic Referral Form
Please attach to e-Referral	
GP STAMP (name, address & phone number)
	Name of Hospital      	
	ED 	MAU 	Other Department 	
	Name of referring consultant team and contact phone number:      	
Patient details
Name: 
Sex: 
D.O.B: 
Address:

Tel. No: 
Carer’s name:      
Carer’s Tel. No:      	Date of referral: 	
	Interpreter needed                   Yes/No
Language?      	
	Date of seizure: 

Patient history      
	Current drug therapy:      	
	Please ask a witness to come with the patient to clinic or provide phone contact details here if this is not possible:      	
Referral Guidelines	
Above 16 years old		
New onset seizures or blackouts (Syncope should not be referred)		
Patient has made a full recovery from event		
Not under a neurologist for seizures/blackouts (please refer back to the team involved)		
Patient information sheet given out		
For patients referred from hospital settings		
Bloods exclude infection or metabolic derangement		
Imaging (CT or MRI) excludes a space occupying lesion (please discuss acute management with the appropriate specialty)		
ECG normal