Varicose Veins Surgical Treatment Referral Form Template

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Appendix B
Varicose Veins Surgical Treatment Referral Form
Please complete the following policy checklist before referring your patient for
varicose veins surgery or for an opinion on management. Any referrals which do not
include this form will be returned to you for completion.
PLEASE COMPLETE THE FORM IN BLOCK CAPITALS
Section 1: Referring GP’s details
Name of Referring GP
Date of Referral
Surgery address
Section 2: Patient Details
Name of Patient
Date of Birth
Patient’s Address
Patients weight at time of
referral
Patients BMI at time of referral
Varicose vein surgical treatment referral form
Commissioning (PS28)
Issue 2
Approved 02/12/2010
Expiry 23/03/2012
Page 1 of 2

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