STH Neuro Vascular MDT Referral Form

The Neuro Vascular MDT is held on Friday mornings. Referrals must be completed by 12 noon on the Thursday. Urgent opinions can be sought from the on-call team at other times.

IT IS THE DUTY OF THE REFERRER TO INFORM THE PATIENT THAT THEY ARE BEING REFERRED TO THE NEUROVASCULAR MDT REGARDING THEIR REFERRING SYMPTOMS/DIAGNOSIS AS THE PATIENT MAY HAVE ACCESS TO THE MDT OUTCOME. THIS IS TO AVOID UNDUE PATIENT ANXIETY.

If there are issues with this electronic form, paper-based referrals can still be made using the referral form emailed to sth.NVMDTNeurosurgery@nhs.net.

– Referrer Information

Responsible Consultant/GP (Required)

Consultant/GP's Email Address (nhs.net emails only) (Required)

Referring Speciality (Required)

Hospital/GP Practice (Required)

Referrer's Name (Required)

Referrer's Email Address (nhs.net emails only) (Required)

Referrer's Contact Phone Number for Referral Queries (Required)

Email Address for MDT Outcome (only provide a single, valid nhs.net email address) (Required)

+ Patient Details

Patient Name (Required)

Patient Date of Birth (Required)

Patient Age

NHS Number

Gender (Required)

Patient's Home Address (Required)

+ Neuro-Vascular Pathology

History of Presenting Complaint (Required) (maximum 500 characters)

Primary Diagnosis (Required)

Population

Hypertension

Age over 70

Size of Aneurysm

Earlier SAH from another aneurysm

Site of Aneurysm

PHASES Score

Details of any Previous Treatment

History of Haemorrhage

Details of 'Other' pathology

Pathology Specific

Key Question To MDT (Required) (maximum 500 characters)

+ Past Medical History

General Past Medical History (Required) (maximum 500 characters)

Rockwood Frailty Score (grade most appropriate) (Required)

Hypertension

Hypertension Combined

Smoking Status (Required)

Epilepsy/Seizures (Required)

+ Imaging

Imaging Hospital

CT Performed

MRI Performed

Please confirm that all basic imaging has been transferred to STH PACs via IEP (Required)

CTA Performed

MRA Performed

DSA Performed

Please confirm that all dedicated imaging has been transferred to STH PACs via IEP (Required)

+ Other

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