Haemochromatosis GP referral form – Northern Ireland Blood Transfusion Service

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 ZIP / Postal Code
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.
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 ZIP / Postal Code

Patient Details