Haemochromatosis Hospital Consultant referral form Please note: This referral form should only be completed by a Hospital Consultant on behalf of a Haemochromatosis patient. Patient DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* MM slash DD slash YYYY H&C Number*Address Street Address Address Line 2 City 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?* 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 historyAny evidence of haemochromatosis related end organ damage including heart and liver* No Yes Unfortunately your patient is not eligible as a blood donor.Management PlanFrequency of venesectionEvery six weeksEvery three monthsOtherPlease provide detailsAlternative 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 DetailsName* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Designation*Email* Enter Email Confirm Email Address Street Address Address Line 2 City