EMIS Forms

August 2020 update: We are currently updating this page to contain the latest forms, however, if you don't find what you are looking for, please check the relevant service page.

For any support or help installing, please email the IT & Systems Team

Use Ctrl + F if you can’t find what you are looking for.




 Imaging 

GP Direct Access Imaging Request form – UCLH (June 2020)

InHealth DEXA Referral Form (26 October 2018)

URGENT (Non-Cancer) US Imaging Request Form (adult and paed) – RF (7 September 2020) 

See the Cancer section above for the following forms: 

  • Rapid Diagnostic Centre (RDC) for Non-Specific Symptoms Suspected Cancer Referral Form 
  • Urgent Direct Access Imaging Request Form (adult and paed) - Suspected Cancer - NCL FORM_V2 

 


 All other forms (in alphabetical order) 

Anticoagulation Service – RFH v.2.1 (10 February 2014)

Audiology Assessment London Hearing AQP Over-50s Referral Form (28 November 2013)

Audiology Assessment RF or RNTNE Under-50s Referral Form  (8 July 2013)

Bereavement service referral form - Camden, City, Islington and Westminster (2 February 2021)

Bladder and Bowel Care Service (Incontinence) (December 2017)

Breathe Stop Smoking referral form  (December 2020)

Camden Care Navigation and Social Prescribing Service Referral Form v1.1 (1 September 2020)

Camden Carers Professional Referral Form (22 October 2020)

Camden Children's Physiotherapy Referral Form RFH (9 November 2018)

Camden Community Children's Services SPOR Form (December 2017)

Camden Community Drug Treatment Service Referral Form (10 March 2020)

Camden Community Health Podiatry Referral Form (December 2017)

Camden Community Health Referral Form – CNWL (October 2020)

Camden Community Phlebotomy Referral Form (22 October 2020)

Camden Integrated Care Service Referral Form (14 March 2016)

Camden & Islington Practice Based Mental Health Service PBMH

Camden Learning Disabilities Service (CLDS) Referral Form (14 December 2020)

Camden MSK Referral Form (v.1.4) (28 February 2019)

Camden Sport and Physical Activity Service

Cardiology Investigation Referral Form – RF (November 2016)

Catheter Clinic Referral Form – CNWL (4 January 2019)

Children's Community Atopy (Asthma & Eczema) Clinic Referral Form v.1.2 (5 July 2017)

Child Weight Management Service (27 April 2016)

CMHAAT Referral Form (December 2017)

COPD Screening Form (3 February 2014)

Coil and Implant Service JWP referral form (February 2021)

Diabetes Prevention Programme Referral form (8 September 2020)

Diabetes Prevention Programme Referral invitation letter (8 September 2020)

Direct Access RFH/RNTNE Audiology Proforma (8 July 2013)

Drug and Alcohol Service Referral Form (19 November 2013)

DVT Ultrasound Request Form RFH (28 February 2019)

ECG - GP Request for Cardiac Investigation - Whittington (February 2021)

Exercise Referral and Adult Weight Management Referral Form (5 July 2016)

Facial Pain Clinic – UCLH Referral Form (3 September 2018)

GP Request for Cardiac Investigation - Whittington (February 2021)

iCope Referral Form (6 April 2016)

Infertility Referral Form – Camden CCG v1 (13 August 2020)

Imperial College (St Mary's) Pathology Request Form (10 February 2014)

IRIS Camden Referral Form (29 December 2017)

London Hearing AQP Referral Form (9 December 2013)

Minor Surgery DES Referral Form v.1.0 (18 January 2018)

MOSAIC SCAS Referral Form (24 April 2015)

MSK Pain Assessment and Management Service (CPAMS) (December 2017)

NCL Anticoagulation Referral Form

NCL Maternity Services and Information Sharing Referral Form (21 February 2018)

NCL SMR patient invitation letter v1.1 (25 February 2021)

NHS Low Calorie Diet Referral NCLCCG v7 (28 October 2020) 

NLP Perinatal Mental Health Referral Form (21 February 2018)

NOAC Referral Form – Royal Free v.1 14 July 2015

Neurophysiology Referral Form - Royal Free (15 March 2018)

North Central London Diabetic Eye Screening Programme Referral Form (16 December 2020)

Pain Management Centre UCLH (11 September 2018)

Pelvic Health Physiotherapy Referral Form (28 June 2018)

Podiatry Referral Form – RFH (24 July 2018)

PoLCE Referral Form v.5.1 (13 February 2019)

Rapid Access Chest Pain Clinic – Royal Free (3 September 2018)

Rapid Access Chest Pain Clinic, UCLH (3 September 2018)

Rapid Response Team – CNWL referral form (April 2016)

Rehab and Reablement Referral Form - August 2017 (August 2017)

Renal Colic non-contract CT KUB referral form (28 January 2020)

Renal Colic Referral Form (20 March 2018)

Routine (Non-MSK or H&N) Ultrasound Imaging Request Form (Adult and Paed) - RF (1 December 2020)

Sleep Clinic referral

Teledermatology Referral Form – NCL_APR2020 (April 2020)

Telederm Referral Form - v2.8

TAP Referral Form (15 August 2016)

TIA Service at the Royal Free (13 July 2018)

TIA Service at UCLH (13 July 2018)

Trypanosoma cruzi serology request form V1 (February 2021)

Urgent ENT Clinic UCLH RNTNE (11 February 2019)

Urology (Routine) Referral Form (20 March 2018)

Weight Management Services (Adult) Referral Form (5 July 2017)

Wish+ Referral Form (5 February 2015)

About these forms

The latest pre-formatted referral forms for your practice systems are listed on this page - most of the new forms we're getting are now ready for EMIS Web systems only.

Once you have installed the referral forms on your system, you can edit them to reflect practice details. See the document on installing referrals forms for EMIS Web.

The IT & Systems team will be able to help you with problems relating to these referral forms and getting them to work with your practice system. 

e: nclccg.itandsystems@nhs.net