Memory assessment service referral form

The memory assessment service (MAS) provides a single point of access for all patients with suspected dementia.  Do not use this form for self-referrals. Self-referrals are only made by calling the service and if you have previously been with the service and been informed that you can contact us again.

The contact number for the service is 0300 303 5342 If you are unsure of whether to refer, please call to discuss with the team.

Referrals which do not include reference to relevant blood tests having been requested/completed may be returned to the referrer.

Before you start, this form requires you to have the following:

  • full set of dementia screening bloods within six months
  • patient consent 
  • GP agreement
  • basic cognitive screening test such as 6CIT, MMSE OR GPCOG
  • ruled out any physical or mental health causes of cognition change.
Are you a GP? *

Please stop filling in this form and use the SystmOne referral form available at your practice.

Are you are a registered Dorset HealthCare professional? *

Please stop filling in this form and call the service on 0300 303 5342.

Have you discussed this with the patient and their GP? *

Please make the GP and the patient aware of the referral. Please continue completing this form in the meantime

Have you have ruled out other physical or mental health causes of cognitive changes? *

Please stop filling in this form and refer back to the GP

Are you able to provide comprehensive blood results within the last six months? *

Please stop filling in this form and refer back to the GP

Patient details

Ex-Armed Forces? *

GP details

Referral details

Is this a... *

Contact details

Do we have consent to contact this person? *

Administrative information

Please note, initial contact will be made my telephone
Has patient given consent to leave a message? *
Has patient given consent for text messages? *
Is an interpreter required? *
Is the patient housebound? *
Is the patient a wheelchair user? *
Has this referral been discussed with the patient, and/or their relative if they lack capacity? *

History and examination

Please note if you have significant concern you can contact MAS on 0300 303 5342 to discuss the case over the telephone
Please confirm that you have completed a physical examination on the patient *
Please confirm that other reversible causes of cognitive decline been excluded *

Please do not submit the form as we cannot accept this referral

Medical history

List of medication

Memory Assessment Service (MAS)