Complete Patient Care referral

Our nurses are ready to help you and your patient. By completing this form, you are confirming that your patient wishes to be registered with myqufora, where they will be provided with ongoing guidance and support from our experienced nursing team.

To help us support your patient safely and effectively, please complete all fields. Your patient will automatically be registered to receive their product from Qufora Direct.

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Patient Details

Patient NHS Number *

Title *

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Telephone Number (mobile numbers are a good way for us to confirm any appointments) *

Patient Alternate Telephone Number (should we not be able to reach you on the above)

Patient Email Address (email is a good way for us to confirm any appointments)

Name of Parent/Guardian to contact *

Parent/Guardian Telephone Number *

Parent/Guardian Email Address

Patient Address *

Address Line 1

Address Line 2

City

Post Code

GP Details

GP Practice Name *

GP Contact Number

GP Address *

Address Line 1

Address Line 2

City

Post Code

GP Email Address

What part of Complete Patient Care you would like your patient to receive? *

Teach product and follow up
Change product
Follow up and support
Perform annual review

Teach product and follow up

We will teach and provide tailored follow-up for your patient for a minimum of three months and include an annual review.

Change product

We teach your patient their new Qufora product and new regime then provide tailored follow up for a minimum of three months.

Follow up and support

Whenever your patient needs that extra support with their Qufora product, at any time in their treatment - we will provide tailored follow up and support to suit their needs.

Perform annual review

We will carry out ongoing annual reviews with your patient and their Qufora product.

Contra-indications excluded *

Please provide more information regarding the contra-indications *

Are there any relative contra-indications (cautions) to consider *

Please provide more information regarding the relative contra-indications *

Patient Consent

Please confirm below that your patient has agreed to :

proceed with rectal irrigation *

proceed with rectal irrigation

receive contact from a Qufora Nurse Specialist *

receive contact from a Qufora Nurse Specialist

Please note that both of the above options need to be selected to proceed.

This confirmation is required to proceed.

Please select your patient's predominant symptom *

Constipation
Faecal Incontinence
Mixed
Incomplete Emptying/Evacuation
Mucus Plug/Leakage
Unknown
Other

Please provide further information for the other predominant symptom *

Please select the type of constipation *

Slow transit
Functional
Opioid Induced

Please select type of incontinence *

Passive
Post defaecation seepage
Urge
Overflow

Please select your patient's underlying diagnosis: *

Functional Bowel Disorder
Low Anterior Resection Syndrome (LARS)
Multiple Sclerosis
Obstetric Trauma
Rectocele
Spina Bifida
Spinal Cord Injury
Unknown
Other

Types of functional bowel disorders *

IBS-Constipation (Constipation predominant)
IBS-Diarrhoea (Diarrhoea predominant)
IBS-Mixed (Alternates between Diarrhoea and Constipation)
Functional Constipation
Functional Diarrhoea
Evacuatory Dysfunction
Faecal Incontinence

At what level was the injury sustained? *

Please provide further information for the other diagnosis: *

Is your patient prone to Autonomic Dysreflexia *

Rescue medication available *

Product and Regime

What product are they currently using?

Product and Regime

Please select the type of irrigation type required for your patient in line with the decision guide. ( Click here if you wish to access the guide).

Current Product

MiniGo
Mini
MiniGo (Small)
Cone
MiniGo Flex
Balloon
MiniGo Flex (Small)
Flow
Klick
Non-Qufora Product
Bed

Which product are they currently using

MiniGo
Mini
MiniGo (Small)
Cone
MiniGo Flex
Mini and Extension
MiniGo Flex (Small)
Flow
Balloon
Klick

Which product are they currently using?

How often does your patient irrigate

Daily
Every second day
At least 3 times a week
Other

As you have selected "other", please give further details of how often your patient Irrigates?

Please enter details of irrigation frequency for each "Other" product your patient is using

Change Choice

MiniGo
Qufora Nurse Specialist to decide
MiniGo (Small)
Flow
MiniGo Flex
Klick
MiniGo Flex (Small)
Bed

Reason for change of product

Type of Irrigation recommended for your patient *

High volume
Low volume
Qufora Nurse Specialist to decide

High volume *

Qufora IrriSedo Flow
Qufora IrriSedo Klick
Qufora IrriSedo Bed

Has the patient been shown the Qufora IrriSedo Bed system *

Is the patient aware of the need for DAILY USE and the time required for irrigation *

Are two carers available to perform the irrigation *

Who will be undertaking the irrigation *

Are they aware of this referral

Please provide contact details for this person/team

Has the patient consented to use the Bed system *

Please provide more information on bed system use *

Initial volume of water (ml)

Low volume *

Qufora IrriSedo MiniGo
Qufora IrriSedo MiniGo Flex

Please select the cone size your patient will require

Regular
Small

When would you require the annual review to be done

As Soon As Possible
Specific Month

In which month would you require the annual review to be completed

January
May
September
February
June
October
March
July
November
April
August
December

Frequency of irrigation

Benefits of rectal irrigation discussed

Risks of rectal irrigation discussed

Has the patient had a rectal examination within the past 3 months *

Is there any reason why a rectal examination has not been performed *

Any significant findings from the rectal examination *

Please state any significant findings from the rectal examination *

Is your patient taking any bowel medication (prescribed or over the counter) ? *

What bowel medication are they taking and how often? *

Patient to continue with same bowel medication regime ? *

Please state changes *

Is your patient taking any other medication (prescribed or over the counter)?

What other medication are they taking and how often? *

Any past medical / surgical / obstetric history *

Please provide further information about past history *

Are there any specific points you would like us to address as part of the follow-up?

Additional Information

Including assistance with irrigation, carer involvement, family support, communication or mobility considerations, and any safety concerns for a home visit

Is there anything else you wish to tell us?

Healthcare Professional Details

Healthcare Professional Name *

Healthcare Professional Job Role *

Healthcare Professional Contact Number *

Healthcare Professional Department *

Healthcare Professional Address *

Address Line 1

Address Line 2

City

Post Code

Healthcare Professional Email *

Your patient will be taught their product and receive ongoing follow up

We will teach their Qufora product and provide tailored follow-up for your patient for a minimum of three months and include an annual review.

Your patient’s product will be changed

We will teach your patient their new Qufora product and new regime and provide tailored follow up for a minimum of three months.

Your patient will receive follow up and ongoing support

Whenever your patient needs that extra support with their Qufora product, at any time in their treatment - we will provide tailored follow up and support to suit their needs.

Your patient will receive ongoing annual reviews

We will carry out ongoing annual reviews with your patient and their Qufora product.

Complete Patient Care referral

Patient Details

GP Details

Teach product and follow up

Change product

Follow up and support

Perform annual review

Patient Consent

Product and Regime

Product and Regime

Additional Information

Healthcare Professional Details

Your patient will be taught their product and receive ongoing follow up

Your patient’s product will be changed

Your patient will receive follow up and ongoing support

Your patient will receive ongoing annual reviews

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