Please Fax Referral Requests To 250-519-5186 You will be sent a copy of the consultation when completed

Revised July 31st 2017

Patient Referral for Periprocedural Warfarin Management

Anticoagulation Therapy Clinic (ATC), Royal Jubilee Hospital 1952 Bay Street, Victoria, B.C. V8R 1J8 Tel: 250-370-8220 Fax: 250-519-5186

Patient Name: Procedure Date: (DD/MM/YYYY)

Patient PHN: Patient DOB: (DD/MM/YYYY) Location: RJH VGH SPH Other Patient Phone: (Preferred number) Procedure:

Referral Criteria: Patient is anticoagulated with warfarin AND meets at least one of the following: Mechanical heart valve

History of previous stroke

Previous VTE while on warfarin or thrombophilia

Acute thrombotic event (DVT/PE) within the 3 months prior to the planned procedure

Recent Coronary stent and on dual antiplatelet therapy

Atrial Fibrillation and CHADS2 of 4 or higher (CHADS2 score 1 point for each of the following conditions: Congestive Heart Failure; Hypertension; Age Greater than 75 years; Diabetes; 2 points for history of Stroke or TIA)

Please NOTE: If the above criteria are not met, a fax-back letter declining the consult will be sent to the referring clinician. I request the Clinical Pharmacy Specialist to do the following:

1. Contact the patient and advise them of the appropriate date to discontinue warfarin and antiplatelet therapy (if applicable), if appropriate

2. To arrange bridging antithrombotic medications and provide patient with instructions, if indicated

3. To advise the patient regarding the restart of warfarin and antiplatelet therapy, if applicable, after the procedure is completed

I authorize the clinical pharmacy specialist to arrange prescriptions under my name for heparins or oral anticoagulants in accordance with his/her recommendations (if indicated), including refills if required, should the initial amount be insufficient. I also authorize the clinical pharmacy specialist to order the required laboratory assessments required under my name (e.g. INR, pTT, CBC, eGFR) Referring Physician (Signature) _________________________________ CPSID#________________

Physician Name (Printed) ______________________________________ Date: __________________