The Nelson Health Centre Direct Access Cardiac Diagnostics Referral Form
If this form does not contain all the required information, it will be returned.
Fax no. 020 8725 4215 Email nelson.referrals@stgeorges.nhs.uk
Forename:
DOB:
M□ F□
Surname:
Address
GP details:
NHS no.
Email:
Tel
Referral Date:
Medical History / Risk Factor:
Existing IHD Smoking HX Diabetes Hypertension Hyperlipidaemia
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Family HX
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Diagnostic Test Request:
Please tick tests required:
ECG□
24 ECG Monitor □
48 ECG Monitor □
72 ECG Monitor □
BP monitor □
Event Recorder □
Exercise Test □
Echo □
Please note: All cardiac investigations that are deemed to be normal will be sent back to
referrer with a cardiac physiologist’s report only. Abnormal investigations will be reviewed by
cardiologists and a report sent back to the referrer with clinical recommendations. If you wish
to refer for a cardiology consultation please refer using the generic referral form.
Please add any relevant information:
Signature of Referrer ________
Excellence in specialist and community healthcare
Date ______