If you’re a clinician or counsellor working with patients with cardiac inherited disease, below you’ll find all the forms you need for referring them to CIDG and adding them to the Cardiac Inherited Disease Registry.
Registry Information (12-Jan-2012)
CIDG Patient information sheet about the registry- must be read by the patient or next of kin prior to consenting.
Long QT Patient Information (12-Jan-2012)
CIDG Patient information sheet on Long QT syndrome.
Brugada Syndrome Patient Information (12-Jan-2012)
CIDG Patient information sheet on Brugada syndrome.
ARVC Patient Information (12-Jan-2012)
CIDG Patient information sheet about ARVC
DCM Patient information (12-Jan-2012)
CIDG patient information sheet on Dilated Cardiomyopathy
HCM Patient Information (12-Jan-2012)
CIDG Patient information sheet on Hypertrophic Cardiomyopathy.
Sudden Death Information Sheet (12-Jan-2012)
CIDG information sheet for families of sudden death victims
Clinical Consent (07-Feb-2012)
Consent form to register a patient into the registry (to store clinical details). Must be signed by the referring clinician or coordinator and the individual or by parent/guardian. To register a deceased family member, next of kin must sign.
Blood Consent (07-Feb-2012)
Consent form to store DNA and to perform genetic testing. Must be signed by the referring clinician or coordinator and the individual or parent/guardian. To test or store DNA from a deceased family member, next of kin must sign.
ECG Report for CIDG (11-Jan-2012)
Form for clinicians to use to report an ECG for subjects being investigated by CIDG.
SD1 Referral – Pathologist to LabPlus CIDG (January 2017)
Form for Pathologist to use to refer specimens in sudden death cases to CIDG and LabPlus.
SD2 Referral – Pathology referral to CIDG (January 2017)
Referral form for Pathologist to use to refer sudden death cases to CIDG for review.