Referring to the electrophysiology department

Instructions for completing Electrophysiology referral form

Please include the patient’s name, date of birth, hospital and/or NHS number and contact details.

All referrals must specify the Consultant’s name and hospital/clinic address.  

It is important to include as much clinical history as possible to enable the correct tests and optimal protocols to be selected.

Please include a summary of the relevant clinical details and the reason for referral e.g., to aid diagnosis, to monitor progression or efficacy etc. If to aid diagnosis is there a differential or suspected diagnosis?

Indicate whether mydriatics can be used or whether contraindicated.

If the patient has significant allergies,  please let us know.

Specify whether there are any safeguarding issues or additional factors that may affect our ability to examine the patient e.g., hearing, mobility, learning difficulties.

Indicate when  an interpreter is needed, and the required language.

If there is a medical need for urgent or “soon” testing, please be specific and explain why the patient should take priority over others. If you require further advice on priority please contact the department to speak to one of our clinical scientists before submitting your referral.

Referrals may also be sent in the post but ideally to be emailed to  following address: moorfields.electrophysiology@nhs.net  

Useful  information

1. Current & presenting symptoms.  One or both eyes (simultaneous or sequential)
   Onset, duration (when), sudden or gradual.  Stable, progressive, transient, central or peripheral. Exacerbating factors (e.g., hot baths), Pain, Difficulties with colour vision, bright lights, night vision. Positive phenomena (e.g., flashes of light).
2. Past ophthalmic history.  Any known or presumed diagnosis, eye infections/ injuries/ surgery (e.g., for cataract). Vision in childhood. Any retinal imaging or neuroimaging and when? Spectacles (how old is prescription & reading or distance)
3. Past medical history. e.g., epilepsy, diabetes, hypertension, malignancy, bowel/gastrointestinal issues, kidney or liver disease, arthritis or autoimmune disease
4. Drug history e.g., present/ past use of chloroquine/hydroxychloroquine, ethambutol, immunosuppression, desferrioxamine, quinine, vigabatrin, chemotherapy, anti-retroviral, vitamins
5. Family history.  Including parents, children, siblings & distant relatives (maternal or paternal)
6. Social history. Occupation, diet, alcohol/recreational drugs, exposure to toxins or lasers
7. Allergies. Medications, food, materials  (e.g., latex).