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