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Get PSD/HOF001/GB/DC 2014-2024

Priate including ward) Inpatient Outpatient Date of Birth GP/Consultant Name Address GP/Consultant contact details Postcode Contact Telephone If already on enter recent INR and dose record Current Medication (please specify Anti-platelet drugs and other interacting medication) To continue when INR is therapeutic Y/N Date INR dose (Five most recent results & dose) Aspirin …..…….. mg daily ……….mg daily please fax recent prescription with the for.

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