Warfarin Care Enrolment

Patient Details

Patient First Name *

Patient Surname *

Patient DOB *

Patient Sex *

Male

Female

Patient Street Address *

Patient Suburb *

Patient Postcode *

Patient State *

Patient Phone

Patient Mobile *

Contact with Results (INR, Dosage, Date of Next Visit) * This is the person we send the SMS messages to with dosage details.

Carer Details

Carer Name

Carer Mobile

Referring Doctor (Specialist must include patient’s GP)

Referring Dr Name *

Street Address *

Suburb *

Postcode *

State *

Phone *

Email *

General Practitioner (GP) Copy from above

GP Dr Name *

Street Address *

Suburb *

Postcode *

State *

Phone

Email

History

Medical History *

Hospital Admission if applicable

Hospital

Ward

Warfarin History

Date warfarin therapy commenced

Target Range *

2.0 - 3.0

2.5 - 3.5

Other

Expected duration of warfarin therapy *

Short Term

Long Term

Clinical indication *

Mechanical heart valve

A.F.

Pulmonary Embolism/DVT

Recurrent P.E./DVT

DVT

Other

INR test dates and warfarin doses *

INR *

Dose *

Date

INR

Dose

Date

INR

Dose

Date

INR

Dose

Date

INR

Dose

Current Medication (or attach summary below) including herbal medications, vitamins and dietary supplements. Note start/stop date if recent:

Medical documentation Include up to 5 files

Medical history attachments Choose files

Terms & Conditions

Important notice to referring Doctors/Nurse Practitioners

• This Warfarin Care service provided by 4Cyte Pathology Pty Ltd (4Cyte) is an automated service that communicates INR test results and Warfarin dosing instructions via text message. As a consequence, all patients enrolled into this Warfarin Care service, or their carers, must have access to and the ability to use a mobile telephone.

• This Warfarin Care service is a free service offered by 4Cyte to the patients of 4Cyte’s referring practitioners. In order to provide this service free of charge, 4Cyte requires ongoing cooperation and compliance with 4Cyte’s Warfarin Care testing and dosing process by both enrolled patients and you as referring practitioner.

• You must provide 4Cyte with prompt notice of any change to the management of enrolled patients which you become aware of, including:

(a) changes to medications;

(b) the enrolled patient undergoing medical or dental procedures;

(c) the enrolled patient being admitted or discharged from a hospital; and

(d) the non-compliance by the enrolled patient with testing and dosing instructions.

• The ongoing participation of the enrolled patient in the Warfarin Care service and the Warfarin dosing of the enrolled patient is at all times at 4Cyte’s discretion. 4Cyte reserves the right to, at any time:

(a) refer the enrolled patient back to you for dosing; and/or

(b) discharge the enrolled patient from the Warfarin Care service and transition them back to you as their referring practitioner,

if 4Cyte is not able to safely prescribe a Warfarin dose to the enrolled patient on the basis of the patient’s presentation, information available to 4Cyte or if an enrolled patient persistently, without reasonable excuse, fails to respond to 4Cyte’s text messages or to comply with 4Cyte’s Warfarin dosing instructions or INR testing requirements.

• You, as referring practitioner, remain primarily responsible for the care of the enrolled patient at all times.

• By proceeding with the enrolment of this patient, you acknowledge and agree to these conditions.

I agree to these Terms and Conditions.

Finalise

Completed By *

Completed on

Warfarin Care Enrolment

FOR PRIVATE HOSPTIALS, GENERAL PRACTITIONERS & SPECIALISTS

Patient Details

Carer Details

Referring Doctor (Specialist must include patient’s GP)

General Practitioner (GP) Copy from above

History

Hospital Admission if applicable

Warfarin History

Terms & Conditions

Important notice to referring Doctors/Nurse Practitioners

Finalise