Please enter the relevant details
Refering Doctor:
Reply E-Mail:
Contact Phone:
Patient Name:
Is this patient for Inpatient transfer?:  
Yes No
Date of Birth:
Sex:  
Male Female
 
Your Hospital:
Type of referral:
Please enter the following details if available
Diabetic:
Yes No
COPD?   
Yes No
Carotid u/s
Yes No
%Max Stenosed    (either side)
previous peripheral arterial surgery?
Yes No
Neurological dysfunction affecting ADLS
Yes No
Previous Cardiac Surgery (requiring opening pericardium)
Yes No
 
Serum Creatinine (micromol/L)
>200 <200
Active endocarditis
Yes No
Critical preoperative state
Ventical Fib/Tachy Inotropes?
CPR? Intraaortic BP
Intubated? Anuria/oliguria (<10mls/Hr)
Unstable angina
Yes   No
LVEF
>50% 30-50% <30%

Recent infarct (<90 days)
Yes No
Pulmonary hypertension (PA pressure > 60 mmHg)
>60mmHg <60mmHg
Info

For faster referral processing please make sure all the necessary information is obtained. To view this please see 'What we require' .














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