Emergency Referral Form - For Use by Medical Professionals only

Emergency/Medical Referral Form

For use by Medical Professionals /authorised person
Name of Child

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Address of Child

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
Parent/Guardian Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Do the Family Receive any of the following benefits

Tax CreditsChild Tax CreditsHousing BenefitCouncil Tax BenefitIncome SupportUniversal Credits
Do you have a medical exemption certificate with your benefits to allow you to have free prescriptions/glasses etc .....
Child Diagnosis
What type of travel help is needed and how often, please include as much info as possible.
Car Registration Number
Date first Travel is Required
Person making this Referral

First NameLast Name
Position
example: NICU Nurse
Signature

Clear
Date Referral Made

MonthDayYear
Date
Any other Information
GDPR - I understand that personal Information will be Gathered by Daisy Chains IW in order for them to assess us for help, this information may be gathered from a medical professional, health Care worker or from you the family of the child. I understand that once my information is gathered by Daisy Chains IW they will need to share this with travel companies to be able to book the travel we need to undertake. For the purposes of this they will only share , Name, Car Reg, E-mail address and in some cases Telephone Number. Information that is gathered will be stored as per our Data Protection Policy and will only be held for as long as we are still involved with the charity or no longer than 3 years after last contact- upon a child turning 18 all records will be deleted.

I agree to the aboveI do not agree to the above
Emergency Referral Guidelines

Emergency Ferry Travel is for families based on the Isle of Wight who have a child transfered to the mainland for treatment or care.

1. Island Child that needs to attend mainland hospital for immediate ( within 24 hours) care and does not qualify for ambulance assistance.

2. Island child in an inpatient at a mainland hospital and has been diagnosed with a long term health condition, life limiting condition or disability and parents need to travel to be with them.

3.Newborn /Premature baby born to Island family that has been born at or transfered to mainland hospital and parents need to travel to be with baby.

4. Child making regular trips to the mainland for essential treatment or care.

Referrals must be made by a medical proffesional caring for the child and they must make the referral on the information they have available to them ensuring the above criteria is met.

Ferry Travel is booked by us and a booking confirmation will be sent directly to the family via email or text.

All information is kept confidential and only for as long as the family need our support, it will not be passed on to any other parties and will only ever be used for the reasons intended as stated in our full Confidentiality and GDPR policy.
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Emergency/Medical Referral Form