NHS e-Referral Service
Vascular Service request form
ALARM CONDITIONS: Patient with any of these symptoms should be referred immediately. You should not
use NHS Referrals.

Blood Clots/ Blood Flow Problems requiring Carotid Duplex – refer to TIA/ Stroke service – not on NHS Referrals

Deep Vein Thrombosis – not on NHS Referrals
SECTION 1: PATIENT DEMOGRAPHIC DETAILS
Patient NHS number:
UBRN:
Patient first names:
Patient last name:
Date of Birth (DD/MM/YY):
Gender:
Male
Female
st
Patient address (1 line):
Patient town / city:
Patient postcode:
Patient contact number:
Patient contact number 2:
SECTION 2: REFERRER INFORMATION
First name:
Referrer role:
Last name:
GP
On behalf of GP
GP Practice Code:
Referrer contact no:
GMC Registration No:
Referrer e-mail address:
SECTION 3: TEST SERVICE REQUEST
Priority:
Routine
Urgent
Does the patient have an infection or do they pose an infection risk to others?
Yes
No
Test requested: (please tick one only)
Aortic Aneurysm Assessment
Only appropriate for male patients over 65
Ankle Brachial Pressure Index Measurement (ABPI)
Please complete Section 4
(Intermittent claudication, peripheral vascular disease)
Must answer ‘Yes’ to at least two questions to be considered
appropriate for referral
Provisional Diagnosis (or symptoms and signs):
Reason for request:
Relevant clinical history:
SECTION 4: ANKLE BRACHIAL PRESSURE INDEX MEASUREMENT
If you answer ‘yes’ to any of the questions below, please ensure that you include any relevant information in the clinical
history section.
Does the patient have any absent pulses?
Yes
No
Is the patient a smoker?
Yes
No
Is the patient known to suffer from hypertension?
Yes
No
Does the patient have hyperlipidaema?
Yes
No
Is the patient known to have diabetes?
Yes
No
Does the patient have a leg ulcer?
Yes
No
Does the patient have a family history of arterial disease?
Yes
No
Does the patient have claudication?
Yes
No