ACUTE STROKE REFERRAL – Form

 

  • All patient transfers to public and private hospitals for endovascular clot retrieval (ECR) are subject to local hospital business rules and policies.
  • Name of person completing this form
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  • First Name *
  • Email *
  • Last Name *
  • Contact Telephone *

  • Clinical History
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  • Patient First Name *
  • Patient Last Name *
  • Patient Date of Birth (DD/MM/YYYY) *
  • Patient Address
  • Patient Contact / Phone Number
  • Patient Medicare Number *
  • Patient Health Fund
  • Patient Health Fund Membership Number
  • Name of Patient Next of Kin
  • Patient Next of Kin Phone Number
  • GP Name
  • GP Contact Telephone
  • Referring Doctor Name *
  • Referring Doctor Email Address:*
  • Referring Doctor Provider Number *
  • Referring Doctor Contact Telephone:*
  • Time of Stroke Onset or Last Seen Well (24 hour format)*
  • Time of Presentation to Hospital (24 hour format) *
  • Time of CT Scan (24 hour format) *
  • tPA given * Yes  No 
  • Time tPA Given (24 hour format)
  • Reason tPA not Given *
  • Presenting Hospital *
  • NIHSS at Presentation *
  • Site of Vessel Occlusion *
  • Patient Weight (kg) *
  • Patient Allergies*
  • Other Comments (Including Allergies, Fasting Status, GCS, Site of Occlusion,
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  • I, {{fname}} {{lname}}, hereby certify that I have obtained consent from to disclose the personal information listed above. * Yes  No 
  • I have contacted 1300 4 STROKE (1300 4 787653) and spoken to the on call INR *
  • I have called 000 to arrange emergency ambulance transfer *
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