Incomplete Forms Will Be Returned to Referrer and Investigation Not Booked

EXTERNAL REFERRAL FORM FOR PACEMAKER AND ICD INSERTION

PATIENT DETAILS Name: D.O.B: Address: NHS number:

Post Code: Patient Contact Number:

REFERRING CONSULTANT: REFERRING HOSPITAL: Kingston / St Heliers / Epsom / Royal Surrey / Frimley / East Surrey / St Peter’s/ Other……………………...

INDICATION FOR REFERRAL (FOR NEW PATIENTS):

ECG: Exercise Tolerance Test: 24-hour Holter:

PROCEDURE DETAILS: Pacemaker □ ICD □ Reveal □ VVIR □ DDDR □ BIVENT □ If new ICD patient, have they received counselling? Y □ / N □ New system □ Atrial lead problem- reposition □ Box change only □ Atrial lead problem- new lead □ Wound problems- explore and reposition Ventricular lead problem- reposition box □ □ RV □ LV □ Specify problem: Ventricular lead problem- new lead □ RV □ LV □ Lead Extraction: A □ RV □ LV □ System □ System upgrade □ Specify reason: System/ box removal □ Type of connector if box change: IS1 □ UNI 5/6MM □ DF1 □ Other □ Last FU date: MEDICATION: On Warfarin Y □ / N □ Stop ___ days before admission? Y □ / N □ On N.O.A.C.S Y □ / N □ Stop ___ days before admission? Y □ / N □ On aspirin Y □ / N □ If yes, continue? □ On clopidogrel Y □ / N □ If yes, continue? □

Underlying Rhythm? Y □ / N □ Temporary wire required? Y □ / N □ Anaesthesia required: GA □ LA □ Admission status: Elective □ Day case □ Signed Job title: Print Name: Bleep: Date: INCOMPLETE FORMS WILL BE RETURNED TO REFERRER AND INVESTIGATION NOT BOOKED Telephone: 02087254958/4406 Fax: 02087250329 Email: [email protected]