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Microsoft word - nbac intake form.doc

Dear Doctor: Thank you for referring your patient to the Newport Beach Anticoagulation Clinic (NBAC). Please complete and sign the order below. Your signature indicates that you are requesting the Anticoagulation staff to manage your patient according to Newport Beach Anticoagulation Clinic Coumadin Titration – Standard Procedure. If your patient is unable to comply with the clinic protocol (i.e. missed three appointments or does not follow dosing directions), the patient will be returned to your care for continued anticoagulation management. NBAC will notify you if your patient’s INR results are <1.5 or >4.5 or there are any significant changes in care. This referral allows NBAC to place standing orders for PT/INR as needed for patient. To enroll this patient in the clinic, please provide the following:  Write this referral order for up to 1 year. Indicate the ICD-9/Diagnosis code, INR goal range and your UPIN on the order and fax this referral to: (949) 335-4607.  Patient demographics including insurance information.  A brief history and physical. Indicate any high risk or co-morbidities the clinic staff may need to closely monitor while patient is on anticoagulant therapy.  A current medication list.  Instruct your patient to call the Newport Beach Anticoagulation Clinic at (949) 407-6200 to: 1. Schedule a telephonic interview to be admitted into clinic 2. Inform the clinic which lab will complete the PT/INR testing and set a date for the first draw. NBAC will notify you once the patient enrollment into clinic is complete. Until then, this patients Coumadin management remains under your guidance.
Please specify the reason for referral to the Newport Beach Anticoagulation Clinic:
Diagnosis/ICD-9 Code: ____________________________________________
Goal for INR:
Standing Lab order for PT/INR as needed and fax results to NBAC at (949) 335-4607 Anticoagulation Doctor (print name): ________________________________________ UPIN: ___________________________________________ Start Date: __________________ Anticipated End Date: ________________ Please fax completed order to: (949) 335-4607 (Include face sheet for Hospital Patients) FAX: (949) 335-4607 www.anticoagclinic.com Anticoagulation Clinic Referral Form
1. PATIENT INFORMATION
Patient Name:

Caregiver/Contact Name:
Patient Home #:
Check if patient is high risk for bleeding or thromboembolic event Yes
2. DIAGNOSIS (Check box)
Mechanical heart valve
Orthopedic: prophylaxis for knee/hip replacement surgery
Atrial fibrillation
Prevention of DVT in post-op high risk
DVT (deep vein thrombosis)
Cerebral embolism
Phlebitis & thrombophlebitis
Heart valve transplant
Pulmonary Embolism Iatrogenic
Left ventricular dysfunction
Pulmonary Embolism Infarction
Acute Myocardial Infarction
Primary hypercoagulable state
ICD9:_____________________
3. PATIENT MEDICAL HISTORY
Heart Failure
Lives alone
Vegetarian
Alcohol Use*
Peptic Ulcer Disease
Arthritis
*Alcohol abuse is a contraindication for Warfarin therapy
IVDA/EtOH Abuse
5. WARFARIN INFORMATION
Hypercholesteremia
Initiation of therapy (in last 10 days) Yes
Hypertension
Warfarin start date____/______/_________
Mental Health
Cancer of

Last INR ___________ Date_________
GI Bleed
Hx of Falls

Patient is currently on Lovenox (LMWH) Yes
Cognitive Impairment
Current Warfarin Tablet Strength _________(mg)
Thyroid Disease
Hepatic Disease

Diabetes Mellitus
Current Dosing Regimen
Seizure Disorder
Renal Insufficiency
Pulmonary Disorder
Other _______________________________
6. MEDICATION LIST
Medication

Frequency
Start Date
Referring Physician Signature ______________________ Date ___________________
Appointment made by clinic after receipt of referral. Physician has responsibility of patient’s
anticoagulation care until the clinic notifies the physician that the patient is enrol ed in the clinic.

Source: http://www.anticoagclinic.com/public/NBAC_Patient_Referral.pdf

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