Roche CoaguChek XS Plus, Training Manual

Page: 64 / 78

64 CoaguChek Professional Monitoring Systems
Training Manual
14
Appendix one
Anticoagulation Clinic Referral Form
Patient Name: Date of Birth:
Address:
Telephone number:
GP Referral
Yes
!
No
!
If Yes, provide name of GP practice
Consultant Referral
Yes
!
No
!
If Yes, provide name of consultant hospital
Clinical condition requiring anticoagulant:
Target and range:
Concurrent medical conditions:
Concurrent medications
Date anticoagulant commenced:
Length of treatment: End date:
Current dose: Previous INR results:
Signature of clinician: Date: