Special Patient Notes
This form should NOT be used for patients with a Terminal Illness – Please use the Notification of Patient Requiring
Palliative Care Intervention form (ref: OPS-F-012) available from the Badger office on 0121 766 2120.
Patients Details (please use Block Capitals)
This information may be shared with external agencies? Yes / No
This information may be shared when attached to a case? Yes / No
This information should be reviewed on: ………………………………… (date)
Signed ………………………………… Print Name ………………………………...
Surgery ………………………………… Date …………………………………
Please return during office hours to:
Duty Team Leader, Badger House, 121 Glover Street, Birmingham B9 4EY
Fax: 0121 766 5135 For further information Tel: 0121 766 2120
Please telephone Badger to confirm receipt
For BADGER use only:
Data added to the system Date: _______ Initial: _____
Surgery has contacted to confirm receipt Date: _______ Initial: _____