Proforma for approval of referral for consideration of varicose vein surgery patient details

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Date of Referral:

Date Referral Received:

GP Practice:

Referring GP:

Patient Name:

Patient Date of Birth:

Patient Address:

Patient Contact Number:

NHS Number:

Hospital Number (if known):

Grade of Vein for which Surgery is Being Requested (see overleaf), please specify

Patients presenting with bleeding varicosities should be referred immediately

Grade III

Grade IV

Grade V

Which Provider (and clinician, if appropriate) does the patient wish to see? Please specify

POLICY CRITERIA – the full policy is accessible via this link

Please refer to the form overleaf and complete as appropriate in order to demonstrate compliance with the commissioning policy and appropriateness of referral.


Are there any co-morbidities that need to be considered before surgery?

(please provide details above)

Yes No

Have relevant co-morbidities been optimised as far as possible and the patient is willing to consider surgery at the time of referral?

Yes No


Exceptional Clinical Circumstances:

For patients who do not fall within the eligibility criteria set out in the policy but where there is demonstrable evidence that the patient has clinically exceptional circumstances, an Individual Funding Request may be considered. The referring clinician should consult the Commissioner’s “Operational Policy for Individual Funding Requests” document for further guidance on this process.

REFERRAL CRITERIA: Please tick all that apply and note the policy status for differing grades

Policy Status

Grade Of Varicose Vein




Specialist advice & surgery NOT commissioned

0: Thread/Flare/Reticular

Telangectasias are small red / blue venular flares.

Reticular veins are easily visible small blue veins (less than 3mm diameter), not associated with large vein valvular incompetence.

These may be unsightly but are of cosmetic concern only.

☐ Cosmetic concerns

☐ Telengectasia (small red blue venular flares)

☐ Retinacular veins (easily visible small blue veins < 3mm diameter)

I: Without Symptoms

Patients with truncal varicosities which may be associated with large vessel valvular incompetence but are asymptomatic.

☐ Visible varicosity

II: Uncomplicated

Uncomplicated varicose veins with symptoms such as pain, aching, heaviness or swelling in the absence of ulceration and/or skin changes.

Mild itching

☐ Aching

☐ Mild oedema

Refer for specialist advice

III: With Complications

Patients who have had obvious thrombophlebitis, bleeding from varicose veins or present with objective evidence of venous hypertension – pitting oedema, lipodermatosclerosis or varicose eczema

☐ Current or previous thrombophlebitis

☐ Bleeding

Pitting odema

☐ Lipodermatosclerosis

☐ Varicose eczema

Prompt referral recommended

IV: Signs of Venous Insufficiency

This group includes patients with healed varicose ulcers, inflamed lipodermatosclerosis, infected varicose eczema and severe extensive thrombophlebitis. Initial management may include compression stockings, anti-inflammatory drugs and antibiotics as appropriate.

Severe thrombophlebitis may be associated with DVT; aspirin or subcutaneous low molecular weight heparin should begin prior to referral.

If a DVT is suspected, refer via the DVT pathway.

☐ Healed varicose ulcer(s)

☐ Inflammed lipodermatosclerosis

☐ Infected varicose eczema

☐ Severe extensive thrombophlebitis

Refer once ulcer has healed

V: Active leg ulceration

Patients who develop leg ulcers should be referred to specialist community-based ulcer clinics where arterial disease can be excluded; venous ulcers may then be treated with compression bandaging.

Ulcers not responding or recurring despite prophylaxis using compression stockings require further assessment.

☐ Venous leg ulceration

NOTE: Sufficient clinical information must be provided to confirm the grading of varicose veins

Page of

Worcestershire CCGs Referral Form – Varicose Veins Policy V3 June 2017

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