Referral Proforma: Royal Free Early Inflammatory

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Referral Proforma: Royal Free Early Inflammatory Arthritis Clinic
This is a Rapid Access Clinic with access to ultrasound for the early diagnosis and
management of suspected rheumatoid arthritis only.
Referrals will only be accepted if the patient meets a minimum of 3 of the following
criteria:
Please tick box
1. Symptom duration ≥ 4 weeks
□
2. Tenderness and/or swelling at ≥ 2 joints
(not including DIP, 1st CMC or 1st MTP joints)
□
3. Involvement of the small joints
(hands, feet, wrists)
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4. Positive Rheumatoid Factor or Anti-CCP antibodies
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5. Elevated Inflammatory Markers
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Please undertake the following investigations at the Royal Free Hospital or if done
elsewhere please give the patient a copy of the results to bring to their clinic
appointment.
Please tick box
FBC, U&E, LFT
□
ESR, CRP
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Rheumatoid Factor, Anti-CCP antibodies
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ANA
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Xray hands, feet (only if affected & done at Royal Free)
□
Patient Name
Address
NHS Number
Telephone Number
GP Name
Address
Telephone Number
Signature
Please either attach completed form to ‘choose and book’ referral or
alternatively Fax for attention of Dr Pamela Mangat: Fax 0207 830 2428, Tel
0207 830 2284
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