New consultation

Submit a patient to the haematology team for review. Fields marked * are required.

Please include all relevant clinical details below. The haematology team reviews each referral carefully, and incomplete submissions may be returned so we can offer the safest advice for your patient. Thank you for taking the time to complete each section fully.

Patient

Basic identifiers and location.

MRN*

Name*

Surname*

Date of birth*

Sex*

Ward / location*

Known to haematology?*

Clinical

Reason, specific question, history and current/relevant medications.

Reason for consultation*

Specific clinical question to be answered*

Relevant past medical history*

Current/Relevant medications

ECOG performance status*

Relevant blood results

Enter the most recent results available.

Full blood count *

Hb*

WCC*

Neuts*

Lymphs*

Plts*

Coagulation screen

APTT

INR

Fibrinogen

Renal / liver

Creatinine

Calcium

Bilirubin

LDH

Other relevant blood results

Relevant imaging

Summarise recent imaging findings (modality, date, key results).

Imaging findings*

Biopsy results

Summarise any relevant biopsy findings if available (site, date, histology).

Biopsy findings

Referral

Urgency and how to reach you.

Urgency*

Responsible consultant*

Referring clinician*

Mobile number*

Mobile number only — no bleeps

HSE email*

Must end in @hse.ie