REQUEST FOR SURGICAL OUTPATIENT APPOINTMENT - FAX 03 4215 1383 OR E-REFER USING REFERRAL NET

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

Referral to:
Barwon Health Outpatients

Service requested: Service request

Urgency: Urgency
Why urgent? Why urgent?
Referral valid for:  Referral vaild for
If Oral/Maxillofacial: If Oral/Maxillofacia
If Gynaecology:  Gynaecology Ix		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
HPI-O:  
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number
HPI-I:  

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
IHI:  Patient Demographics.IHI Number

		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 

Interpreter required: Interpreter required		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Language required		Medicare Number: Patient Demographics.Medicare Number	
ATSI:  ATSI status		Private Health Insurance 	
TAC or Workcover: TAC or Workcover?		Pension Card Number:  Patient Demographics.Pension Number	

HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways

CLINICAL INFORMATION
Reason for patient referral: 
Referral reason	
Is this a recurrent problem?: Recurrent problem?
Is this a 2nd referral for the same problem: 2nd ref same problem	
Previous relevant consultants or unit involved in Mx of problem or related problem:
Previous Consultant	
Radiographic imaging provider: Radiographic imaging	
Recent PHx Medication list review undertaken: 
Review PHx meds	
Warnings: Clinical Details.Warnings	
Allergies: Clinical Details.Allergies	

Current Medication:
Clinical Details.Medications Current Regular	
Social History:
Clinical Details.Social History	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Investigation Results:
Clinical Details.Result List (Selected)	

Signed: Dr

Treating Doctor.Name

Date: Miscellaneous.Date