Medications Please attach most up to date list including allergies and adverse drug reactions
Social history
Additional Information / Reason for Referral Please attach any relevant clinic letters
Referring Dr / Nurse................................................................................................................................. Signature................................................................................................................................................. ECG Attached
Echo Attached
Please fax your referral to one of the following numbers: For Huddersfield GPs 01484 347811, FAO Anne Molloy, Tel 07507595081 For Dewsbury GPs 01924 463281, FAO David Fearnley, Tel 07773364028
Please don’t hesitate to ring the Heart Failure Nurse Specialist if you wish to discuss the patient prior to completing the referral form
3.8
Kirklees Community Healthcare Services is responsible for providing NHS services in Kirklees and is part of Kirklees Primary Care Trust.