:

REFERRAL FORM
Deep Vein Thrombosis (DVT)

affix patient label

Page 1 of 1

Patients Tel. No: Patient Home Telephone /
Patient Mobile Telephone 

  GP surgery: Registered GP Organisation Name Referring clinician contact number: Organisation Telephone Number 

Referred from: (please tick)	 GP	 ED	 Urgent Care SBCH	 OTHER       

Relevant Past Medical History/ Drugs/ Allergies:
     

Presenting symptoms/length of time of symptoms:
     

  
   IF ANTICOAGULATION STARTED.- DATE STARTED:      	 TYPE?      

   D/DIMER	 YES	NO                 RESULT      	WELLS SCORE      

  CLINICIANS NAME (Please print): Free Text Prompt                            CONTACT NUMBER: Organisation Telephone Number                                                                                          
 DATE: Long date letter merged 

Please contact Thrombosis Clinic:
In hours on 01173424684 or via switchboard.
Out of hours please email this referral form to ThrombosisClinic@uhbw.nhs.uk or leave an ansaphone message on 01173424684 with above details on form.
Thrombosis Clinic open MON-FRI. 09.00 – 17.00 SAT– SUN and bank holidays 09.15 – 13.00
Thrombosis Clinic, A413, Level 4 Queens Building, Bristol Royal Infirmary BS2 8HW

Document Version 1.0 (Feb 06)	Review Date: Feb 08	Author: Rachel Heneker

Allergies 
Consultations 
Investigations 
Medication 
Problems 
Blood Pressure 
HbA1c 
Height 
Weight 
BMI