New consultation

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

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