Anticoagulation - referral form - updated 19 09 13
Anti-coagulation referral form
Highlighted sections are compulsory. Any incomplete referrals will be returned.
Referrer:
Patient details:
Name……………………………………………….
Surname………………………………………
Designation…………………………………………
First name…………………………………….
Address………………………….
D.O.B:………………………………………….
……………………………………………………….
Gender:……………………………………….
Postcode…………………………………………….
Address……………………………………….
Tele No………………………………………………
…………………………………………………
Email…………………………………………………
Postcode…………………………………….
Tele No………………………………………
Mobile……………………………………….
Name (If different)………………………………….
Email…………………………………………
Address………………………………………………
NHS number….…………………………….
……………………………………………………….
Postcode…………………………………………….
Telephone…………………….…………………….
Reason : ………………………………
Diagnosis:
Diagnosis – Does not fit Criteria:
Retinal Vessel Occlusion
Other; (please state)………………………………….….
Date of diagnosis…………………………………………
Date commenced on Warfarin:…………………….
Loading dose…………………….………
Current Warfarin dose……………………………….
Range…………………………………….
Next INR due date…………………….…
Last four INRS:
Medway Community Healthcare CICRegistered office: 5 Ambley Green, Bailey Drive, Gillingham, Kent ME8 0NJTel: 01634 382777Registered in England and Wales, Company number: 07275637
Infection control status:
Is the patient known to have any infections?
A recent history of vomiting and/or diarrhoea?
If yes date of onset and last episode?.
Please list medications history:
Drug Yes / No
MedicalHistory: (please indicate)
Once completed please post to: Anticoagulation Service, St. Bartholomew’s Hospital,
New Road, Rochester, Kent ME1 1DS
For office use only:
Date form received in anti-coagulation service……………………….
……………………………….
Date and time………………………………………………………………………………………………
By whom:………………………………………………………………………………………………….
Patient wishes to be seen at: (clinic name)…………………………………………………………….
Date and time of 1st appointment……………………………………………………………………….
By whom……………………………………………………………………………………………………
Date and time………………………………………………………………………………………………
Referral incomplete – sent back to referrer
Date and time………………………………………………………………………………………………
By whom………………………………………………………………………………………….
Medway Community Healthcare CICRegistered office: 5 Ambley Green, Bailey Drive, Gillingham, Kent ME8 0NJTel: 01634 382777Registered in England and Wales, Company number: 07275637
Source: http://www.medwaycommunityhealthcare.nhs.uk/_uploads/documents/forms/referral-forms/anticoagulation-referral-form.pdf
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