REQUEST FOR COLPOSCOPY CLINIC APPOINTMENT - 	FAX 4208 0844			

GP Referral
		Referral Date: <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to:
Colposcopy Clinic
Dr Anne Hotchin
Suite 2, 43 Little Myers Street
Geelong
Phone: 4208 0842
Fax: 4208 0844

Current HCC card? <<Pt must hold current HCC for referral to be accepte>>		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
	
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Consumer details:
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>

		Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>

Alternative Contact: 

 
		DVA Number: <<Patient Demographics:DVA Number>>	
		Insurance: <<Patient Demographics:Health Insurance>>	
Pension Card Number: <<Patient Demographics:Pension Number>>		Medicare Number: <<Patient Demographics:Medicare Number>>	

Clinical Information:		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>>

Reason for patient referral: 
Referral Criteria:
Pap Smear Abnormality for colposcopy: <<Pap Smear Abnormality for Colposcopy >>
Please arrange a colposcopy as per NHMRC guidelines
<<Other Information for Referral>>

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Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>> 

Current Medication:
<<Clinical Details:Medication List>>

Social History: <<Clinical Details:Social History>> 

Past Medical History: 
<<Clinical Details:History List>>

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Progress Notes: 
<<Summary:Progress Notes (Selected)>>

Investigation Results:
<<Summary:Investigation Results (Selected)>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>