Great Ormond Street
London WC1N 3JH
Tel: 020 7405 9200
Fax: 020 7813 8404
GOSH Centre for Endocrine and Metabolic Diagnostics – Referral form
Please fax completed form to 0207 813 8404
Please note that this is a diagnostic service only and is only available to our agreed list of referrers. GOSH will
not take over the ongoing care of the patient and will return test results to the referrer for interpretation. If you
wish to referrer to one of the Endocrinology or Metabolic consultants for opinion or ongoing care this should be
done in the usual way by sending a referral letter. Urgent referrals, including those for rapid assessment can be
discussed with the on-call Endocrinology or Metabolic consultant via the hospital switchboard.
New patient

Known to GOSH

GOSH number if
known:
Patient
Surname:
Forename:
Date of Birth:
NHS No:
Address:
Postcode:
Tel. no:
Interpreter needed (state language):
Referrer Details
Name:
Address:
GP
GP Practice Code:
Dr:
Address:
Post code:
Tel no:
Fax no:
Email:
Clinical Details
Problem list:
Post code:
Tel. no:
Fax no:
Email:
Great Ormond Street
London WC1N 3JH
Tel: 020 7405 9200
Fax: 020 7813 8404
Is this a known MRSA + patient?
Yes
No
Investigations required (please tick):
Programmed Investigations
Controlled fast
Glucose profile (24 hr)
Cortisol profile (24 hr)
Glucagon stimulation
Oral glucose tolerance
Water deprivation
GnRH
Short Synacthen
3 day HCG
3 week HCG
Dexamethasone suppression
Overnight GH profile
Skin biopsy for fibroblast culture ☐
What tests are fibroblasts to be sent for:
Blood Investigations
Plasma amino acids
Plasma homocysteine
Acylcarnitines
Very long chain fatty acids
7 dehydrocholesterol
Ammonia
White cell enzymes hepatosplenomegaly
Other – please specify:
Urine Investigations
Organic acids
Amino acids
GAG
Lactate
Transferrin isoelectric focussing
Plasma purines and pyrimidimes
Plasma guandinoacetate
Vacuolated lymphocytes
White cell enzymes – Neuro screen
White cell enzymes – Dysmorphic
screen
Purines
Urine sulphite
Urine guadinoacetate and creatinine