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Refer a patient

Anti-coagulation - Referral form

Patient details
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Is an interpreter required? * required


House bound? * required



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Referrer:
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(ie GP/Consultant/Nurse)
* required
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Please check all those that apply:











How many DVT/PE recurrences?:




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


Have risk and benefits of treatment been considered before initiation? * required


Please indicate your drug history: * required
Check all those that apply





























Infection control status:
Is the patient known to have any infections? * required



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



Previous medical history: * required
Please check all that apply






Last four INRs:
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Please indicate Target INR & Range:
Target INR: 2.5 / Range: 2 to 3: * required


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


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


* required
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.

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.

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