Leeds CCGs Targeted Interventions Referral Form
Hospital Referral for Varicose Vein Surgery
Referral to:
(insert patient’s choice of hospital)
Patient Details:
Title
Surname
Forename(s)
Address
D.O.B
NHS Number
Tel (home)
Tel (mobile)
Gender
Ethnicity
Age
Is an interpreter required
Yes
No
Is transport required
Yes
No
Referrer Details:
Referring GP
Practice Address
Telephone
Fax
Practice Code
Tick appropriate box indicating reason for referral
Itching, discomfort and aching of affected leg causing marked interference with daily life
associated with visible and/or palpable varicose veins following an unsuccessful trial of conservative
treatment for a minimum of 6 months
Chronic skin changes for a minimum of 6 months (please indicate which are present)
Eczema,
Haemosiderin deposition
Lipodermatosclerosis
Ulceration
More than one episode of minor haemorrhage from a ruptured superficial varicosity
A single significant haemorrhage from a ruptured superficial varicosity, especially if transfusion of
blood was required
Recurrent superficial thrombophlebitis following an unsuccessful trial of conservative treatment for
a minimum of 6 months
Severe and persistent pain and swelling interfering with activities of daily living and requiring
repeat analgesic medication. Unsuccessful trial of conservative treatment for a minimum of 6 months
Recurrent varicosities following surgery
Indicate approach taken to clinical management of the patient prior to referral:
Clinical Notes:
Past Medical History:
Review Date: April 2016
Drug List:
Allergies:
GP Signature:
Date:
Supporting evidence
Aetna clinical policy bulletins http://www.aetna.com/cpb/medical/data/1_99/0050.html accessed July
2013
Randomised clinical trial, observational study and assessment of cost-effectiveness of the treatment
of varicose veins (REACTIV trial) JA Michaels, WB Campbell, JE Brazier, JB MacIntyre, SJ
Palfreyman, J
Ratcliffe and K Rigby Health Technology Assessment 2006; Vol. 10: No. 13
Shows that surgery for varicose veins is effective for severe varicose veins with reflux.
National Institute for Health and Care Excellence.CG 168 Varicose veins in the legs.
http://www.nice.org.uk/guidance/index.jsp?action=byID&o=14226 accessed July 2013
Review Date: April 2016