LIVERPOOL ANTICOAGULATION SERVICE

Tel. No: 0151 247 6066
Safe Haven Fax: 0151 247 6060

Referral for Primary Care Based Anticoagulation Monitoring

Please complete fully to ensure the referral is processed in a timely manner
preventing delay in the patient’s treatment and care.

Urgent Referral: Please contact us to discuss prior to submission
Date of Next INR:
Section A: Patient Demographics
Name: / Address:
D.O.B:
NHS Number: / Patient Telephone Number:
GP : / Next of Kin / Carer Name Telephone Number: /
N.B. if the patient is a temporary resident please indicate here:
If YES,
We understand you may not have all the clinical information. We would appreciate it if this information could be forwarded to the service as soon as you receive it. Please complete as much as possible.
Section B: Clinical Information
Name of Oral Anticoagulant:
(Vitamin K antagonist only, e.g. Warfarin)
Indication for Therapy:
Date Anticoagulant Commenced:
Target INR:
INR Range:
Duration of Therapy:
Review Date:
Previous Monitoring Arrangements:
Section B: Clinical Information (Continued)
Recent INRs Via Previous Arrangement:
Date of Most Recent Result: / INR Result: / Dose:
Date of 2nd Most Recent Result: / INR Result: / Dose:
Date of 3rd Most Recent Result: / INR Result: / Dose:
Antiplatelet Status:
Is the patient currently on Antiplatelet therapy? /
If YES, please indicate name of antiplatelet(s):
When INR is therapeutic, is the antiplatelet to be continued?: /
If YES, please indicate either: / Lifelong:
No Stop Date Required / Fixed Term:
Stop Date Required
Indication for Antiplatelet:
Does the patient have a history of MI?
Does the patient have a stent?
Additional Relevant Medical History:
Section C: Clinical Summary & Medication
Please attach a clinical summary from your practice system (including a list of all current medication and any allergies that may apply to the above patient).
Without this information, a clinical decision cannot be made about this patient and the referral will not be accepted until this information is provided.
Section D: Blood Requests
Please tick boxes below to indicate that the following bloods have been requested prior to referral. Failure to do so will delay the referral process, subsequently delaying treatment.
Section E: Additional Information (i.e. any perceived risks to health care professionals, aggressive behavior, mental health issues etc.)

APPENDIX 1: HOUSEBOUND CRITERIA

Please take the following into consideration or ask patient/carer prior to referral:

Yes / No
Is the patient a genuine housebound patient and listed as such on your GP clinical system (i.e. do you have to carry out home visits as patient is unable to attend surgery?)
Does the patient use public transport to and from a local clinic?
Does the patient use their own transport to and from a local clinic?
Does the patient have friends, family or carer who could take them to and from a local clinic?
Please Note: If you have answered ‘YES’ to questions 2, 3 or 4, we would ask you to consider a suitable clinic for the patient to attend.
REFERRAL WILL NOT BE ACCEPTED BY THE SERVICE UNTIL ALL INFORMATION IS COMPLETED FULLY ON THE FORM AND A CLINICAL SUMARY IS ATTACHED

I, the referrer, understand that I retain clinical responsibility for this patient by issuing prescriptions. On acknowledgement of this referral, the Liverpool Community Health Anticoagulation Service becomes responsible for the provision of anticoagulation monitoring for the patient.

Name of Referring GP:
Signature of Referring GP:
Date of Referral:
Practice Stamp:
If your practice does not receive acknowledgement of this referral within 14 working days, we recommend that you contact the service on 0151 247 6066 to ensure that the referral has been received.

Updated: September 2015Page 1 of 4

Review: September 2017