CAMBRIDGE CARDIOVASCULAR CLINIC Referral Letter Template ================================================================ To: Cambridge Cardiovascular Prevention Clinic ACCI Building, Cambridge University Hospitals Hills Road, Cambridge CB2 0QQ referrals@camcpc.co.uk +44 (0) 1223 256653 From: Dr ______________________________________________ Practice _________________________________________ Address __________________________________________ Phone ____________________ Email ____________________ Date: ___ / ___ / ______ ---------------------------------------------------------------- PATIENT DETAILS ---------------------------------------------------------------- Name: ________________________________________ Date of birth: ___ / ___ / ______ NHS number: ________________________________________ Address: ________________________________________ Phone: ________________________________________ Email: ________________________________________ Funding: [ ] Self-pay [ ] Insurance (provider: __________________) ---------------------------------------------------------------- REASON FOR REFERRAL ---------------------------------------------------------------- [ ] Resistant hypertension (BP uncontrolled on >=3 agents incl. diuretic) [ ] Young-onset hypertension (under 40) [ ] Suspected secondary hypertension [ ] Familial hypercholesterolaemia / lipid disorder [ ] Statin intolerance [ ] Complex polypharmacy review [ ] Cardiometabolic risk stratification [ ] Echocardiography (EACVI-accredited centre) [ ] Other: ______________________________________________ Urgency: [ ] Routine [ ] Soon (within 2 weeks) [ ] Urgent (within 5 working days) ---------------------------------------------------------------- CLINICAL SUMMARY ---------------------------------------------------------------- Presenting concern: ___________________________________________ _______________________________________________________________ Relevant history: _____________________________________________ _______________________________________________________________ Current medication: ___________________________________________ _______________________________________________________________ Recent BP readings / investigations: __________________________ _______________________________________________________________ ---------------------------------------------------------------- CONSENT ---------------------------------------------------------------- I confirm the patient has consented to this private referral and to information being shared with Cambridge Cardiovascular Prevention Clinic for the purpose of arranging care. Signature: ________________________________ Date: ___ / ___ / ______ ================================================================ Please return by email to referrals@camcpc.co.uk We will acknowledge every referral within one working day. ================================================================