Blackrock Clinic
Referral Form to Rapid Access Chest Pain Clinic
Tel : 1 800 283 999
Fax referral to 01-2064448
Date of referral:
Patient Name: Referring GP:
Date of Birth: Age:
Address: Address:
Sex: Male Female GP Tel:
Telephone: GP Fax:
Mobile:
1. Cardiac pain at rest, > 20 minutes, unresponsive to GTN Yes No
2. Do you think that the presentation is of an acute coronary syndrome, unstable Yes No
angina, a myocardial infarction or an evolving myocardial infarction?
3. Signs of acute heart failure? Yes No
4. Uncontrolled / symptomatic arrhythmia? Yes No
Please do not hesitate to call the Chest Pain Clinical Nurse Specialist on the above free
phone number if you have any doubts or clinical queries.
Signature of referring GP____________________________________
Office use only
Date Referral received:_________________________Appointment date:_________________________