4Cyte Pathology - Warfarin Dosing Nursing Home Application Form

Warfarin Dosing Nursing Home Application Form

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” to the patient for their completion and submission to 4Cyte.

Step 3: Once the “Referring Practitioner's Warfarin Dosing Application Form” and the “Patient's Warfarin Dosing” 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 recorded at each future INR testing event.
  2. notify the patient’s referring medical practitioner
  3. notify the patient’s nominated general practitioner
  4. notify the patient’s nursing home facility

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

Step 5: Nursing home to arrange a 4Cyte domiciliary collection 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 nursing home and to their managing general practitioner. We recommend that the patient continue taking their usual dose of warfarin until they receive their newest results.

Referring Doctor’s Warfarin Dosing Nursing Home 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

Current Medication

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

General Practitioner (GP)

Nursing Home Details

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. 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).
  3. 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.