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Northern Ireland Blood Transfusion Service > Haemochromatosis Hospital Consultant/GP referral form

Haemochromatosis Hospital Consultant/GP referral form

Please note: This referral form should only be completed by a Hospital Consultant/GP on behalf of a Haemochromatosis patient.

Patient Details
Name*
Prefix First Last
Date of Birth*
H&C Number*
Address
Street Address Address Line 2 City
Laboratory Results (with dates tested)
HFE Genotype*
Please provide dates of tests.
Genotype - Other details
Ferritin (μg/l)*
Please provide dates of tests.
Iron saturation (%)*
Please provide dates of tests.
LFTs*
Please provide dates of tests.
Clinical History
Treatment venesections in past?*
- No
- Yes
If yes, then please provide details of when and where.
History of blood transfusion?*
- No
- Yes
If yes, then please provide details of when and where.
Any other significant medical history
Any evidence of haemochromatosis related end organ damage including heart and liver*
- No
- Yes
Unfortunately your patient is not eligible as a blood donor.
Management Plan
Frequency of venesection
Please provide details
Alternative venesection facilities available if for any reason, the donor does not meet all criteria in UK Donor Selection Guidelines ?*
- No
- Yes
Referring doctor will continue to provide the continuity of care and check iron profile?*
- No
- Yes
Requester Details
Name*
Prefix First Last
Designation*
Email*
Enter Email Confirm Email
Address
Street Address Address Line 2 City

Headquarters Donation Suite Hours*:

Monday:         09:45 - 20:00
Tuesday:         09:45 - 20:00
Wednesday: Closed
Thursday:       09:45 - 20:00
Friday:             09:45 - 16:45

*Please note opening hours may be subject to change.

Main Reception:
028 9032 1414

Appointments Line:
08085 534 653

Donor Enquires:
08085 534 666

Medical Enquiries:
08085 534 669

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Northern Ireland Blood Transfusion Service
Headquarters (City Hospital Complex)
Lisburn Road
Belfast
BT9 7TS

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Carrickmore Session

As a result of industrial action, the donation session on Monday 09 December will close at 7pm.

Wherever possible, can we ask you to attend earlier in the day?

Sincere apologies for any inconvenience this will cause.