4Cyte Pathology - Enrolment Form

Referring Practitioners Warfarin Dosing Application

To be Completed by Referring / Requesting Medical Practitioner

Step 1: Requesting Medical Practitioner to complete and electronically submit the “Referring Doctor’s Application Form” below.

Step 2: Upon submission of this “Referring Practitioner's Warfarin Dosing Application”, we will send a link (via SMS / email) to a “Patient's Warfarin Dosing Application” to the patient for their completion and submission to 4Cyte.

Step 3: Once the “Referring Practitioner's Warfarin Dosing Application” and the “Patient's Warfarin Dosing Application” have been successfully received by 4Cyte, 4Cyte will then if appropriate, accept the application and enrol the patient in the warfarin dosing service. 4Cyte will then:

  1. issue the patient with a 4Cyte warfarin dosing enrolment number which should be recorded by the patient and supplied by the patient to 4Cyte at each future INR testing event.
  2. notify the patient’s referring medical practitioner
  3. notify the patient’s nominated general practitioner

Step 4: Referring / Requesting Doctor to issue the patient with two pathology request forms:

Step 5: Patient to attend a 4Cyte collection centre at a date determined by the Requesting Medical Practitioner with the pathology request forms issued at (Step 4) and quote their issued warfarin dosing service enrolment number.

Step 6: 4Cyte will issue dosing recommendations to patient via SMS and to their managing general practitioner.

We recommend that the patient continue taking their usual dose of warfarin until they receive their newest results.

If you are enrolling a patient of a nursing home complete the Warfarin Nursing Home Enrolment form here instead.

Referring Doctor’s Warfarin Dosing Application Form

Referring / Requesting Doctor

Patient Details

This is the person we send the SMS messages to with dosage details.

Carer (if applicable) Details

Patient's Medical History

Hospital Admission if applicable

Warfarin History

Min: 1.5 Max: 4.0

Current Medication

including herbal medications, vitamins and dietary supplements. Note start/stop date if recent:
Include up to 5 files

General Practitioner (GP)

Terms & Conditions

Important notice to referring Doctors/Nurse Practitioners

  1. I have personally assessed and confirm that this patient meets each criterion applicable as outlined in “Criteria for Enrolment” as outlined here.
  2. This warfarin dosing service provided by 4Cyte Pathology is a digital service that communicates INR test results and warfarin dosing instructions via text message. Consequently, all patients enrolled into this warfarin dosing service, must have direct and continual access to and the ability to use a mobile telephone to read and respond to SMS instructions. In addition, as part of a digital service, the patient must be proficient and able to access and use email and webforms to correspond with 4Cyte.

    I have personally assessed and confirm that this patient meets this requirement.
  3. I understand that the 4Cyte warfarin dosing service imposes certain obligations and responsibilities upon the referring doctor, the managing general practitioner, the warfarin dosing service, and the patient.

    This includes communication of such obligations and responsibilities to the patient and the patient’s general practitioner (where the referring doctor is different from the patient’s general practitioner).
  4. 4Cyte retains the right to discharge any patient from the warfarin dosing service if it is in 4Cyte’s opinion, that the patient’s care is at risk or cannot be optimised with this dosing service. In these circumstances, the patient will be discharged back to the patient’s doctor for future dosing.

    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.