DIAGNOSTIC TESTING UNIT CLINIC G PODIUM 1 UNIVERSITY COLLEGE

DIAGNOSTIC D’ACCESSIBILITÉ ET DE SÉCURITÉ LATRINE
DIAGNOSTICO DE LA EMPRESA Y SU ENTORNO
UNIDAD DE NEURORRADIOLOGIA DIAGNOSTICA Y TERAPEUTICA

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1 KULTIVAČNÍ DIAGNOSTICKÉ METODY KULTIVAČNÍ METODY PATŘÍ K MODERNĚJŠÍM
11 GUÍA DE REFERENCIA DEL SISTEMA DE DIAGNOSTICO DE

Cardiac referral form

DIAGNOSTIC TESTING UNIT CLINIC G PODIUM 1 UNIVERSITY COLLEGE



Diagnostic Testing Unit

Clinic G, Podium 1

University College Hospital

235 Euston Road

London NW1 2BU

Telephone: 0845 1555 000 Ext 73120

Direct dial: 0203 447 3120

[email protected]

Website: www.uclh.nhs.uk

Request for Cardiac Investigation

PATIENT DETAILS

GP DETAILS

Title     

Name     

Surname     

Surgery     

Forename     

     

Hospital No     

Tel     

DOB     

Fax     

Ward/Dept     

Name referring GP if different from above     

Consultant     

     

Address     

GP Signature     

Postcode     

     

Telephone     

Date     


SERVICE

REQUESTED

CURRENT MEDICATIONS

Routine ECG ( restricted opening time) see below

Transthoracic Echocardiogram

     

24 Hour Tape

24 Hour Blood Pressure

     

PRESENTING SYMPTOMS

     

Chest pain

Oedema

     

Shortness of Breath

Syncope

     

Recurrent Palpitations

PND/Orthopnoea

     

Other:     

     

     

WHAT QUESTION DO YOU WANT ANSWERED BY THIS TEST?

     


     

     

CLINICAL DETAILS

ALLERGIES: NKDA








Cardiac Investigations Request Form notes


  1. 12 Lead ECG ( walk-in service with restricted opening time)

Opening times: Tuesday: 13:30-16:45, Wednesday: 09:00-16:45 and Thursday: 13:30-16:45


  1. Transthoracic Echocardiogram

Indications:

  1. For suspected heart failure with an abnormal BNP (please input value below) or ECG (please attach)

BNP:_______

  1. New atrial fibrillation or atrial flutter 'once heart rate controlled e.g. once mostly <100bpm at rest

  2. Suspected angina

  3. Known hypertension ( no previous echocardiogram )


  1. 24 hr holter monitoring

Indications:

  1. Syncope or pre syncope

  2. Recurrent palpitations


Investigations are carried out at UCLH. Patients will be provided with clear instructions with their appointment

Please complete ALL sections of the form legibly and email to [email protected]

The department is open 09:00-17:00 Monday to Friday and some adhoc weekends.

Please remember that incomplete forms result in delays to service and inadequate reporting.



















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Tags: clinic g,, diagnostic, university, testing, podium, college, clinic