Hand Transplant UK : Online Referral Form Generated with MOOJ Proforms Basic Version 1.6 Please complete and submit the referral form below *Required information. This is a security field. If you want this form being sent leave the following email field blank: Your Details First Name * Surname * Date of Birth * Address Line 1 * Address Line 2 * Town/City * Postcode * Telephone Number * Email address * Preferred method of contact * Post Telephone Email Limb loss details Date of Limb Loss * Cause of limb removal * Accident Infection Burn Other If Other please specify Note: Transplantation is currently not considered if amputation was performed to remove a tumour or cancer of if you were born without a hand or arm. Side of limb loss * Right Left Both Level of RIGHT limb loss * Please select NONE Hand Wrist Mid forearm Elbow Mid arm Shoulder Level of LEFT limb loss * Please select NONE Hand Wrist Mid forearm Elbow Mid arm Shoulder Medical History Do you have any medical problems? * Yes No If yes, please specify Do you take any regular medicines ? * Yes No If yes, please specify * Do you have any allergies? * Yes No If Yes, please specify Additional Information Please use this area to tell us about any additional information you may feel we should know