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Anti coagulation/Warfarin Clinic referral form

Anti-coagulation - Referral form

To find out how we use this information, our security and your rights visit our privacy page.

You will see a thank you page once the form has been submitted. If you do not see this page then you have overlooked to complete some of the required fields. Please check the form, complete the missing details and resubmit. Thank you.

Patient details

Surname: *Required

First name: *Required

Date of birth: *Required

Date / Date of birth

Gender: *Required

Address: *Required

Postcode: *Required

Home contact number: *Required

Mobile contact number:

E-mail:

NHS number:

Is an interpreter required? *Required

Is an interpreter required?

Yes

House bound? *Required

House bound?

Yes

Reason:

First Language: *Required

Referrer

Name: *Required

Designation: (i.e. GP/Consultant/Nurse) *Required

State surgery/hospital/team: *Required

Address: *Required

Postcode: *Required

Main contact number: *Required

E-mail: *Required

Please check all those that apply:

Antiphospholipid Syndrome

Arterial Thromboembolism

Atrial Fibrillation

Cardiomyopathy

Mechanical Prosthetic

Heart Valve

Recurrence of DVT/PE (please state how many below)

Bioprosthetic Valve

Pacemaker

Other

Other - please state:

How many DVT/PE recurrences?

more than 3

Current Warfarin dosage: *Required

Is a haematology follow up required prior to stopping treatment? *Required

Is a haematology follow up required prior to stopping treatment?

Yes

Have risk and benefits of treatment been considered before initiation *Required

Have risk and benefits of treatment been considered before initiation

Yes

Please indicate your drug history: Check all that apply. *Required

Please indicate your drug history: Check all that apply.

Antibiotics

Steroids

Dipyridamole

NSAIDS

Antiepileptics

Choestyramine

Amiodarone

Amiodorone

Griseovulvin

Aspirin

Cimetidine

Fluconazole

Barbiturates

Glucosamine

Isoniazid

Rifampicin

Levothryoxine

Omeprazole

Sucralfate

St John's Wart

Paracetamol

Phenylbutazone

Propafenone

Propranolol

Statins

Sulfinpyrazobne

Tramadol

Antidepressants

Cranberry Juice

Infection control status

Is the patient known to have any infections? *Required

Is the patient known to have any infections?

Yes

If yes – what are the details?

A recent history of vomiting and/or diarrhea? *Required

A recent history of vomiting and/or diarrhea?

Yes

If yes - Please state date of onset and last episode?

Previous medical history: Please check all that apply. *Required

Previous medical history: Please check all that apply.

GI Bleed

Alcohol

Malignancy

Renal Impairment

Hypertension

Hepatic Impairment

Last four INRs

1. Date:

Date / Date of birth

1. INR:

2. Date:

Date / Date of birth

2. INR:

3. Date:

Date / Date of birth

3. INR:

4. Date:

Date / Date of birth

4. INR:

Please indicate Target INR & Range

Target INR: 2.5 / Range: 2 to 3: *Required

Target INR: 2.5 / Range: 2 to 3:

Yes

Target INR: 3.0 / Range: 2.5 to 3.5: *Required

Target INR: 3.0 / Range: 2.5 to 3.5:

Yes

Target INR: 3.5 / Range: 3.0 to 4.0: *Required

Target INR: 3.5 / Range: 3.0 to 4.0:

Yes

I would like the above patient to be referred to this service. *Required

I would like the above patient to be referred to this service.

The form has been completed to the best of my knowledge. I confirm acceptance of the dosage recommended by the service and will implement any prescriptions required by the patient.

I agree to the privacy policy.