Varicose Veins Surgical Treatment Referral Form Template Page 2

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Appendix B
Section 3: Referral Details
1. Please tick which symptoms your patient has from the table below:
Class
Symptoms
Tick as
appropriate
Moderate
Progressive skin changes of venous stasis
syndrome include:
At least one of
 induration
the following
 lipodermatosclerosis (brownish/purple discolouration
symptoms
applies
on the shin/ankle)
 atrophie blanche (white scarred appearance with
punctuate telangectasiae in the white scarred area C
 corona phlebectasia (crown of veins around the
medial malleolus)
 ankle swelling
Recurrent superficial thrombophlebitis
Troublesome symptoms from varicose veins where
the extent, size and site of the varicose veins are
causing the patient significant functional
impairment.
Significant functional impairment is defined by NHS
Swindon as:
 Symptoms prevent the patient fulfilling vital work or
educational responsibilities.
 Symptoms prevent the patient carrying out vital
domestic or carer activities.
Severe
Venous ulceration, recent or current
At least one of
Bleeding from a varicosity that has eroded the skin*
the following
symptoms
applies:
*Should be seen immediately.
One bleed from a varicosity that is at risk of
bleeding again**
**Should be seen urgently.
2. If your patient has moderate varicose veins only, please tick this box to confirm that
your patient has tried compression hosiery (conservative treatment)
without improvement, and that referral for surgical opinion if still necessary.
YES
3. Please indicate if the patient is suitable for treatment in the Independent Sector
Treatment Centre
YES
Signature of referring clinician: ………………………………………………
Date of referral…………………………
Varicose vein surgical treatment referral form
Commissioning (PS28)
Issue 2
Approved 02/12/2010
Expiry 23/03/2012
Page 2 of 2

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