Get the free Anti-coagulation Referral Form

REFERRAL FOR ANTICOAGULATION Date of Referral. Please return to Anticoagulant Clinic. Croydon Health Services (formerly Mayday Healthcare NHS Trust) Name. London Road Thornton Heath Date of birth.

How to fill out anti-coagulation referral form

How to fill out an anti-coagulation referral form:

1. Start by providing your personal information, including your full name, date of birth, address, and contact details. Ensure that all details are accurate and up to date.
2. Next, provide information about your primary care physician or referring healthcare provider. This should include their name, contact details, and any pertinent details about your relationship with them.
3. In the relevant section, indicate the reason for the referral for anti-coagulation therapy. This could be due to a specific medical condition, recent surgery, or other medical factors that require blood thinning medication.
4. Specify any current medications you are taking, including both prescription and over-the-counter drugs. Be thorough and include the dosage and frequency of each medication. If you are taking any blood thinners or anti-coagulation drugs, make sure to mention them.
5. Describe any previous adverse reactions or allergies to medications, especially those related to anti-coagulation therapy. This is crucial information for the healthcare provider to consider when evaluating your referral.
6. Indicate any relevant medical history, including previous surgeries, procedures, or known medical conditions that could impact your eligibility for anti-coagulation therapy.
7. If you have had any recent laboratory tests or diagnostic imaging related to your condition, provide the results or attach copies of the reports to the referral form. This will help the healthcare provider make informed decisions.
8. Finally, sign and date the referral form to acknowledge that the information provided is accurate and complete. If you have any additional comments or concerns, you can include them in a designated section or communicate them directly with your healthcare provider.

Who needs an anti-coagulation referral form?

1. Patients who have been diagnosed with certain medical conditions, such as atrial fibrillation, deep-vein thrombosis, or pulmonary embolism, may require anti-coagulation therapy.
2. Individuals who have undergone certain surgical procedures, such as heart valve replacement, may also require anti-coagulation therapy to reduce the risk of blood clots.
3. Patients with a history of blood clotting disorders, stroke, or other cardiovascular conditions may also be candidates for anti-coagulation therapy. It is ultimately up to the healthcare provider to determine if someone needs this treatment.

Remember, it is essential to consult with a healthcare professional before starting any medication or treatment. They will assess your specific situation and determine if anti-coagulation therapy is appropriate for you.

For pdfFiller’s FAQs

What is anti-coagulation referral form?

The anti-coagulation referral form is a document used to refer a patient for anti-coagulation therapy.

Who is required to file anti-coagulation referral form?

Healthcare providers such as doctors, nurses, and pharmacists are required to file the anti-coagulation referral form.

How to fill out anti-coagulation referral form?

To fill out the anti-coagulation referral form, healthcare providers must provide the patient's information, medical history, reason for referral, and any relevant test results.

What is the purpose of anti-coagulation referral form?

The purpose of the anti-coagulation referral form is to ensure proper referral and administration of anti-coagulation therapy for the patient.

What information must be reported on anti-coagulation referral form?

The anti-coagulation referral form must include the patient's name, age, contact information, medical history, current medications, reason for referral, and any relevant test results.

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