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Please indicate level of urgency: Diagnostic Heart Failure Clinic Referral Form Urgent within next two weeks or within next six weeks (see below) This service is for first presentation of suspected heart failure. For patients previously diagnosed, please refer to Cardiology by the usual route. Please refer only if the patient has a raised NT-proBNP and symptoms or signs consistent with possible heart failure, Please refer via fax to: 0114 271 5367 or Choose and Book under Cardiology – Heart Failure Diagnosis and Management. Otherwise please or email [email protected] Please provide a summary giving the patient’s problems/summary items, drug history and allergies The referral should be marked as urgent if the NT-proBNP is greater than 2000 pg/ml Incomplete forms will be returned to the referrer for the additional information and incur delay Name of referrer GP tel. number GP address Sender title and full name Registered GP phone number Registered GP address GP practice GP fax no. Safe haven NHSmail Patient name Address DoB Age Title Forename Surname Patient address - single line Date of birth Patient Age NHS no. Mobile no. Preferred tel. Date of referral Patient preferred telephone Todays date Gender BMI Weight CXR in last 3/12 Latest BMI kg/m2 Latest Weight kg This patient has suspected heart failure and a NT-proBNP level of: pg/ml Registered GP fax number NHS number Patient mobile telephone number Gender Y/N If the NT-proBNP result is normal there is a 5% chance the patient still has heart failure. If this is still strongly suspected refer to a routine cardiology outpatient clinic. Refer to NICE clinical guideline 108 and Map of Medicine for details of heart failure diagnosis and management