Echo requests will be returned to the referrer if: Not on this form Not accompanied by a recent ECG (aids interpretation of ECHO)

PATIENT DETAILS:	GP DETAILS:
Title	<Patient Name>	Referring GP	<Your Name>
Surname	<Patient Name>	Usual GP	<GP Name>
Forename(s)	<Patient Name>	Practice Code	<Organisation Details>
DOB/Age	<Date of Birth>	<Patient Age>	Telephone	<Organisation Details>
Male/Female	<Gender>	Generic email Address	<Organisation Details>
NHS No	<NHS number>	Practice Name	<Organisation Details>
Address	<Patient Address>	Practice Address	<Organisation Address>
Postcode	<Patient Address>	Practice Postcode	<Organisation Address>
Telephone Preferred	<Patient Contact Details>	Translator Required
Telephone Home	<Patient Contact Details>	Specify Language	<Main spoken language>
Telephone Mobile	<Patient Contact Details>

Indication for Echocardiograph (please select)
Please note that echocardiogram is no longer the test of choice for diagnosing patients with breathlessness in whom heart failure is suspected. These patients should have instead NTP proBNP testing and if this exceeds 400pcg/ml refer promptly to cardiology with a referral letter, NTP proBNP result, recent ECG (not mandated if NTP proBNP >2000) and summary print-out. Echocardiogram and further management will be arranged. There are now only 2 categories for GP direct access echocardiography as below. ECG is required prior to echo referral
New murmur Please specify type of murmur…
2. New on-set Atrial Fibrillation (in line with NICE recommendations) If you wish to request an echocardiogram for any other clinical indication, then please refer to cardiology with a recent ECG