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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 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
Prevention of DVT in post-op high risk
DVT (deep vein thrombosis)
Phlebitis & thrombophlebitis
Heart valve transplant
Pulmonary Embolism Iatrogenic
Left ventricular dysfunction
Pulmonary Embolism Infarction
Acute Myocardial Infarction
Primary hypercoagulable state
3. PATIENT MEDICAL HISTORY
Peptic Ulcer Disease
*Alcohol abuse is a contraindication for Warfarin therapy
5. WARFARIN INFORMATION
Initiation of therapy (in last 10 days) Yes
Warfarin start date____/______/_________
Last INR ___________ Date_________
Hx of Falls
Patient is currently on Lovenox (LMWH) Yes
Current Warfarin Tablet Strength _________(mg)
Current Dosing Regimen
6. MEDICATION LIST
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.
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