COMMUNITY PHLEBOTOMY REFERRAL FORM Patient Name NHS Number D.O.B. Address Patient Tel GP Name & Practice Is patient Yes No Referrer Details housebound? Risk assessment Are there any known risks? Are there Yes No other people/pets living in the client’s home that could cause a risk? Are there any known risks associated with the property? Yes No Do the areas around the property have adequate lighting & clear/safe access? Yes No Can client provide access to the property? (if not give details) Yes No Does client have a history of mental health illness, mood swings or face high levels of stress? Yes No Does client have problems with violence, drug or alcohol abuse? Yes No Lab bloods should be sent to: UCLH RFH Bloods to be taken: Fasting Reason for blood test: BIOCHEMISTRY HAEMATOLOGY VIROLOGY Gold Purple Red Renal (Na/K/Cret/Urea) FBC and Differential Other (please specify): LFT ESR Gamma GT Monospot Bone Profile Sickle Screen Cholesterol Hb Electrophoresis Lipids Other (please specify): Urate PSA Gold Thyroid Function Red Cell Folate/Serum B12 CRP Other (please specify): Iron Other (please specify): IMMUNOLOGY Blue Red Prothrombin Time/INR ANA Coagulation Screen Rheumatoid Factors Other (please specify): Autoantibodies Other (please specify): Grey THERAPEUTIC DRUG MONITORING Glucose Red Other (please specify): Drug Dose Time of last dose Purple Other (please specify): HbA1c Other (please specify): ********NB: REFERRAL MUST BE RECEIVED BEFORE 14:00 IF YOU WISH FOR THE PATIENT TO BE SEEN THE NEXT WORKING DAY*********
COMMUNITY PHLEBOTOMY REFERRAL FORM Patient Name NHS Number D.O.B. Address Patient Tel GP Name & Practice Referrer Details Is patient housebound? Yes No Risk assessment Are there any known risks? Are there other people/pets living in the client’s home that could cause a risk? Yes No Are there any known risks associated with the property? Yes No Do the areas around the property have adequate lighting & clear/safe access? Yes No Can client provide access to the property? (if not give details) Yes No Does client have a history of mental health illness, mood swings or face high levels of stress? Yes No Does client have problems with violence, drug or alcohol abuse? Yes No Lab bloods should be sent to: UCLH RFH Bloods to be taken: Fasting Reason for blood test: BIOCHEMISTRY HAEMATOLOGY VIROLOGY Gold Renal (Na/K/Cret/Urea) LFT Gamma GT Bone Profile Cholesterol Lipids Urate PSA Thyroid Function CRP Iron Other (please specify): Purple FBC and Differential ESR Monospot Sickle Screen Hb Electrophoresis Other (please specify): Red Other (please specify): Gold Red Cell Folate/Serum B12 Other (please specify): IMMUNOLOGY Blue Prothrombin Time/INR Coagulation Screen Other (please specify): Red ANA Rheumatoid Factors Autoantibodies Other (please specify): Grey Glucose Other (please specify): THERAPEUTIC DRUG MONITORING Red Drug Dose Time of last dose Other (please specify): Purple HbA1c Other (please specify): ********NB: REFERRAL MUST BE RECEIVED BEFORE 14:00 IF YOU WISH FOR THE PATIENT TO BE SEEN THE NEXT WORKING DAY*********