Booking proforma for Direct Access Outpatient

SEE AND TREAT ONE STOP CLINICfor uterine bleeding

Date of referral:
PATIENT DETAILS
NHS Number: / Gender:
Surname: / Forename: / Title:
Previous surname: / Date of birth: / Age:
Address:
Postcode: / Home Tel No:
Mobile/Day Tel No:
Preferred contact Tel:
PRACTICE DETAILS
Practice Address:
Postcode: / National GP code:
Referring GP:
Practice code:
Tel No:
Fax No:
E-mail:
Interpreter required: Y / N / Any disability: Y / N
If yes, please specify which language: / If yes, please specify:
Ethnic group: / Is transport clinically necessary:
Religion: / (All requests for transport will be reassessed at the point of booking according to DoH criteria and may be declined)

PLEASE SEND TO BICS

REFERRAL CRITERIA
1 / ABNORMAL UTERINE BLEEDING, including HEAVY MENSTRUAL BLEEDING, intermenstrual bleeding, persistent postpartum bleeding AND ONE OR MORE OF THE FOLLOWING:
Failure of six months of Medical Treatment or contraindication to Medical Treatment
(see Heavy Menstrual Bleeding NICE Pathway -
Pathology on ultrasound scan (including FIBROIDS >3cm, suspected polyp) (for ovarian cysts >6cm or abnormal features, add CA125 prior to referral)
Over 45 years old
Quality of Life Severely Affected
MARK AS URGENT (seen within 2 weeks if possible) IF:
Patient is over 45 years of age OR patient with both heavy bleeding and risk factors (high BMI and diabetes)
2 / Lost IUCD (with confirmed intrauterine location by Ultrasound) / difficult removal
3 / Difficult insertion of IUCD
GYNAECOLOGICAL HISTORY
Significant medical history
TEST RESULTS – please note that recent smear result and date, FBC, negative chlamydia result and date (within past 3 months) are necessary for this referral to be processed
Ultrasound (compulsory): / Last Smear Result and Date (compulsory): / HB (compulsory):
Negative Chlamydia Swab within past 3 months (compulsory): / Ferritin: / TSH if appropriate:
COAGS if appropriate: / Allergy: / Latex allergy: YES/NO
Anticoagulant use (aspirin, clopidogrel, warfarin):
CHECK LIST PRIOR TO REFERRAL
Patient is advised to ensure contraception prior to the visit (the procedure will not be performed if any concern)
Patient is aware an outpatient diagnostic/operative procedure might be performed at first visit and is aware they can contact the clinic with outstanding questions not covered by the ‘See and Treat’ leaflet. Patient is aware the procedure is performed under oral/local anaesthetic and is aware that a general anaesthetic is available, but will not be offered on the day.
Referral date
Signature