The Nelson Health Centre Direct Access Cardiac Diagnostics

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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 [email protected]
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 ______
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