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URGENT TIA CLINIC FAST TRACK REFERRAL FORM (Please use ICE electronic referrals whenever possible) A 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'Referred from' section. Tick the appropriate box for GP, ED, OOH, or MAU.
- Enter patient details including Forename, Surname, Date of Birth, Hospital Number, Address, and NHS Number.
- Provide a verified contact phone number for the patient that will be reachable within the next 72 hours.
- Complete the 'Practice Details' section with your GP name, practice address, and telephone number.
- Assess and document clinical features related to TIA symptoms by marking 'Yes' for each relevant symptom and noting the date and time of events.
- Calculate the TIA ABCD2 score based on age, blood pressure readings, clinical features, duration of symptoms, and diabetes status.
- Finally, ensure all information is accurate before submitting your referral via fax to Alison Jones at the provided number.
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