Hand Transplant UK : Online Referral Form

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Please complete and submit the referral form below

*Required information.

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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 *

Level of LEFT limb loss *

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