Haemochromatosis GP referral form Please note: This referral form should only be completed by a Hospital Consultant/GP on behalf of a Haemochromatosis patient. Patient DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* H&C Number*Address Street Address Address Line 2 City ZIP / Postal Code Laboratory Results (with dates tested)HFE Genotype*C282Y HomozygousC282Y/H63D Compound HeterozygousOther - please specifyPlease provide dates of tests.Genotype - Other detailsFerritin (μg/l)*Please provide dates of tests.Iron saturation (%)*Please provide dates of tests.LFTs*Please provide dates of tests.Clinical HistoryTreatment venesections in past?*NoYesIf yes, then please provide details of when and where. History of blood transfusion?*NoYesIf yes, then please provide details of when and where. Management PlanFrequency of venesectionEvery fortnightEvery three monthsOtherPlease provide detailsAlternative venesection facilities available if for any reason, the donor does not meet all criteria in UK Donor Selection Guidelines ?*NoYesReferring doctor will continue to provide the continuity of care and check iron profile?*NoYesRequester DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Designation*Email* Enter Email Confirm Email Address Street Address Address Line 2 City ZIP / Postal Code