Outpatients AD-HOC Clinic Form
Please ensure before you complete this form that you have confirmed room availability and Nursing Support is available with the Outpatients Manager via email. Failure to do this may result in your request being rejected.
Date email confirmation of room availability / nursing support received *
Has Nursing Support been agreed?*
--Please select an option--
Yes
No
N/A
Does this ad-hoc relate to a previously submitted cancelation form?*
--Please select an option--
Yes
No
Enter Cancellation Reference Number
Enter your Email Address*
Select Specialty*
--Please select a Specialty--
Breast
Cardio
Respiratory
Dermatology
Elderly
Endocrine
ENT
Gastroenterology
RDC
Oncology
General Surgery
Gynaecology
Haematology
Neuro Rehab
Neurology
Nephrology
Paediatrics
Pain
Rheumatology
Rheumatology MSK
T&O
Urology
Vascular
Colposcopy
Obstetrics
Anticoagulation
General Medicine
Sleep Medicine
Diabetic Foot
Midwifery
Transnasal
Stroke
Pre Assessment
Other
Name of Clinician/Nurse/Associated Health Practioner*
Date this change is for or start date for new clinic*
Enter EPIC Code*
Clinic Location / Site*
--Please select an option--
OPD C
OPD E
Orpington Hospital
Orpington Health and Wellbeing
Orpington General Outpatients
Beckenham Beacon - Urology
Beckenham Beacon - General OPD
QMS
Chartwell
Cardiac & Respiratory
Paediatrics
The Early Pregnancy & Gynaecology dept
Farnborough Ward
OTHER
Clinic session AM/PM*
--Please select an option--
AM
PM
All Day
Please select visit type(s) for this clinic:*
NEW F2F
FUP F2F
NEW TEL
FUP TEL
NEW e-Clinic
FUP e-clinic
NEW VIRTUAL
2WW NEW
2WW TELEPHONE
VIRTUAL
All Templates for new appointments will be attached to eRS. If this template is exempt please select reason why:*
--Please select an option--
Non eRS service
New Post Admission
Hot Clinic
Attach to eRS
Operational hours - PLEASE CLICK ON THE DAY OR DAYS THAT THIS CHANGE IS FOR
DAY
MON
TUE
WED
THU
FRI
SAT
SUN
AM
PM
Please select at least one checkbox here.
How many patient per time slot? What visit type per time slot - f2f/tel/e-clinic? Also please state new or FUP in the tables below
AM SESSION
NEW
FUP
Start Time
Appointment Time Duration
Clinic Finish Time
PM SESSION
NEW
FUP
Start Time
Appointment Time Duration
Clinic Finish Time
Submit
Cancel
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