GP and Hospital Referrals

Patient Referral Form for Lymphoma MDT

Patient Referral Form for SCT / Car-T Therapy to Lymphoid Team

Patient Referral Form for Stem Cell Transplant Myeloid Team Form

Patient Referral Form for Stem Cell Transplantation to Myeloma Team

Allograft: 100 day post transplant follow up form

Autograft 100 Day Follow Up Form

Annual Post Transplant Follow Up Form

Autoimmune Epilepsy panel request form

Biochemical Genetics Request Form

Bone Marrow Aspirate Request Form

BRCA test request and consent form

CMD Request Form Version 6

Consent for release of GP Lab Results

External Hospitals Request Form Microbiology Version 5

External Hospitals Request Form Microbiology Version 5 (Word document)

Familial Hypercholesterolemia Genetic Request and Consent Form

FISH Request Form for External Locations

Gonococcal Refernce Laboratory Request Form

GP Request Form Blood Sciences Version 13

GP Request Form Blood Sciences Version 13 (word document)

GP Request Form Histopathology

GP Request Form Histopathology (word document)

GP Request Form Microbiology Version 8

Haemochromatosis Gene (HFE) Mutation Analysis

Haemochromtosis Gene (HFE) Mutation Consent Form

Haemoglobinopathy Request Form

Histology form for Surgery in External Hospitals

PNH Screen Additional Information

Request form Alzheimers Biomarkers (word version)

 

Thrombophilia mutation analysis consent form

Thrombophilia screen request form

Trauma referrals

Please contact the on-call team to discuss the most appropriate management for trauma patients, and where necessary the trauma referral form should be completed online here.

A referral form needs to be filled out by your GP and sent to the Memory Clinic at Mercer’s Institute for Successful Ageing.

Please use the following when referring patients to the Memory Clinic:

• Referral guidelines
• Referral form

Referral forms are to be sent to the following address:

Memory Clinic
Mercer’s Institute for Successful Ageing
St James’s Hospital
Dublin 8

SJH PET CT Referral Form

Trauma referrals

Please contact the on-call team to discuss the most appropriate management for trauma patients, and where necessary the trauma referral form should be completed online here.

Aortic Clinic Referral Form

CIT Governance Letter for Catheter Care

Patient Referral Form for Cancer Genetics Service