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Author or Department
Issue Date
Version
Document Ref
Approved By
Approval Date
Next Review
Page 1
Operations
October 10
V1.1
OPS-F-018
B.Moss
October 10
October 18
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)
Full Name
NHS Number
Date of Birth
Telephone Number
Home Address
GP & Surgery
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
Patient Note
For BADGER use only:
Data added to the system Date: _______ Initial: _____
Surgery has contacted to confirm receipt Date: _______ Initial: _____