URGENT TIA CLINIC FAST TRACK REFERRAL FORM (Please use ICE electronic referrals whenever possible) A 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Referred from' section. Tick the appropriate box for GP, ED, OOH, or MAU.
3. Enter patient details including Forename, Surname, Date of Birth, Hospital Number, Address, and NHS Number.
4. Provide a verified contact phone number for the patient that will be reachable within the next 72 hours.
5. Complete the 'Practice Details' section with your GP name, practice address, and telephone number.
6. Assess and document clinical features related to TIA symptoms by marking 'Yes' for each relevant symptom and noting the date and time of events.
7. Calculate the TIA ABCD2 score based on age, blood pressure readings, clinical features, duration of symptoms, and diabetes status.
8. Finally, ensure all information is accurate before submitting your referral via fax to Alison Jones at the provided number.

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