Emergency Referral Form

This form has been designed for Chiropractors by the Royal College of Chiropractors to be used for emergency referral of patients suspected of having a condition that requires immediate medical attention such as cauda equina syndrome, fracture, stroke, MI and or emergency condition. When completed in full, the form includes the essential information required to facilitate A&E triage.

RCC Emergency Referral Form

Guidance for use

  • Using the form involves processing the patient's personal data for which you must gain consent at the time of completion. It seems reasonable that there a legitimate interest, in these circumstances, to process the personal data of the next of kin (see here for further details regarding legitimate interests data processing). If you decide that it is your clinic's policy to utilise the form, you should ensure reference is made to its use in your clinic's privacy policy.
  • In case of an emergency, instruct the patient to present the completed form to their nearest Accident and Emergency Department without delay (i.e. same day) or, if relevant, pass the completed form to ambulance staff.
  • The form is for emergency referrals to A&E only. You should not use this form for urgent or routine referrals to a General Practitioner - a letter is more appropriate in these situations.
  • Ensure you retain a copy of completed forms for your records.