Download AMS referral form - Medicines Management

Referral form - initiation of warfarin slow start regimen
for prevention of stroke and systemic embolism in atrial fibrillation (AF)
Primary care referral to Doncaster and Bassetlaw Hospitals (DBH) Anticoagulation Monitoring service (AMS)
Instructions for use:
1. Initiating primary care clinician to complete and fax form and baseline INR/APTT results and current
medication list to DBH AMS (01302 381482).
a. All sections must be fully completed or responsibility for anticoagulant dosing will remain with
the initiating primary care clinician.
b. Ensure Fax back acknowledgement received from AMS.
2. The initiating primary care clinician to prescribe 28 warfarin 1mg tablets, with the directions: Take 2mg
(two tablets) at 6pm (avoid cranberry), to allow the patient to attend the practice for phlebotomy (seven
days after starting warfarin) and the AMS to provide further dosing/monitoring instructions.
3. A copy of this referral form must be maintained on the patient’s records.
Patient Information:
Referrer Information:
Surname:
Forename(s):
Address:
Practice code:
Practice:
Address:
DoB:
NHS Number:
Tel No:
Tel No:
Fax No:
Date:
Alternative contact (please print):
Tel No:
Responsible GP (please print):
Signature:
Potentially serious interaction?  Yes  No
If yes, please detail and advise of action(s) taken:
Adverse drug reactions:
Reason for anticoagulation: prevention of stroke and systemic embolism in AF
Target INR: 2.5 (2.0 to 3.0)
Duration: Long term
Dose prescribed: 2mg daily at 6pm [2 x 1mg ( brown) tablets]
Date warfarin started:
Date (DD/MM/YY)
Day
Total daily dose in words (mg)
We have advised the patient to attend for a blood test on:
Patient provided Oral Anticoagulant Therapy: Important information for patients (pack)?
 Yes  No Note: NPSA recommend to document that appropriate information has been supplied.
We request that DBH AMS assume responsibility for monitoring this patient’s anticoagulation therapy.
Request received by (please print):
Date:
Time:
Acknowledgment faxed to practice:
Date:
Time:
The information in this fax is confidential and for the addressee only. It may contain legally privileged information. The
contents are not to be disclosed to anyone other than the addressee. If you are not the intended recipient you must
preserve this confidentially and advise the sender immediately by telephone, returning the original fax by post, without
copying, distributing it or taking action relying on the contents of the information as this may be unlawful.