Legacy referral forms 2026

1. Click ‘Get Form’ to open the legacy referral form in the editor.
2. Begin by entering the patient’s name, date of birth, and medical record or social security number in the designated fields at the top of the form.
3. Indicate whether the patient is currently an inpatient or outpatient. If inpatient, provide their room number and expected discharge date. For outpatients, fill in their phone number and alternate contact information.
4. Select the appropriate protocol or order for anticoagulation therapy from the options provided, ensuring to specify any doses or frequencies as needed.
5. Check all relevant indications for anticoagulation therapy and specify any additional medical problems not already noted in electronic records.
6. Choose the goal INR range and duration of anticoagulation from the checkboxes available on the form.
7. Complete the physician's details responsible for interim management, including their signature and date at the bottom of the form.

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