Evelina Children’s Hospital
Westminster Bridge Road
London,
Telephone: 02071887188
Department of Congenital Cardiology
All sections must be completed (block capitals)
Date: __________
Time:
Name of Referring Hospital:
Name of Referring Consultant: __________________________________
Name of Doctor completing the form ______________________________
Contact Telephone Number & Bleep Number
_______________________
Fax number for Referring Department: ______________________________
Patient Details:
Patient Name:
Date of Birth:
Patient Address:
Parent Name’s
Parent’s Contact Number:
Patient’s NHS Number:
Previous patient at GSTT \ ECH
YES \ NO
GP Name & Address
What
question would you like answered by the paediatric cardiology team?
Key Presenting Symptoms:
History:
Relevant Antenatal History:
Previous Medical History:
Current Medications:
Investigations Performed:
Relevant Results
Child Protection or Social Services Information:
For all referrals contact the Paediatric Cardiology registrar and fax the form to
02071884556 and mark for attention of Paediatric Cardiology Registrar.