Patients Tel. No GP Address: Referred from: (please tick)  ED  GP  WARD  OTHER (Please send photocopied ED notes) Relevant Past Medical History/ Drugs/ Allergies: Presenting symptoms/length of time of symptoms: CLEXANE STARTED  YES  NO IF YES, DATE D/DIMER  YES  NO RESULT WELLS SCORE DOCTORS NAME (Please print) : BLEEP: SIGNATURE : DATE : Please refer to Thrombosis Clinic, either fax referral form or hand deliver to box outsideThrombosis clinic level 2 Queens building. The Thrombosis Clinic is a nurse led service; therefore the referring physician is responsible for the follow up of patients with negative scans, except in the instance of patients referred from the emergency department where responsibility will revert to the GP. Clinic open MON-FRI. 09.00 – 17.00 ( last imaging slot 14.30) SAT– SUN 09.30 – 13.00 (no imaging available) Thrombosis Clinic Tel 0117 342 4684 Level 2 QUEEN’S BUILDING Bleeps 2306/ 2859 Bristol Royal Infirmary BS2 8HW