e-Referral for Venesection
To Dr Karan S Makhija, Dr Wojt Janowski, Dr Ritam Prasad, Dr Sam Yuen
Thank you for arranging venesection
Patient First Name
Patient Last Name
Patient Phone No.
D.O.B
Patient E-mail
Patient Address
Check this box if you wish for the patient to also have a review with the Haematologist - additional charge will apply
Does your patient have a history of poor venous access
Yes
No
Indication for venesection
*
Primary polycythaemia
Secondary polycythaemia
Haemochromatosis
Other
Haemochromatosis genetics
*
C282Y homozygous (2 genes)
C282Y/H63D Compound heterozygote
C282 heterozygote (1 gene)
H63D homozygote
H63D heterozygote
S65C +/- H63D, C282Y
Comments
Referring Doctor
Name
*
Provider No.
*
Date
*
Phone
Fax no.
Referrer's E-mail
A copy of this referral will be sent here
Address
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