Download Diagnostic Heart Failure Clinic Referral Form

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