Clinic Referral Form
Referrer Details
Doctor Name
*
Practice Name
*
Practice Address
Provider Number
*
Email
*
Phone
*
Fax
Doctor's Signature
*
Draw signature
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Type signature
Clear
Patient Details
Surname:
*
Given Name:
*
Medicare Number:
*
Date of Birth
*
Contact number:
*
Email:
Address:
*
Biological Sex
Male
Female
Other
SWH URN (if known)
Yes
No
Is the patient of Aboriginal or Torres Strait Island descent:
Yes
No
Interpreter Required:
Yes
No
Language Required:
Referral Reason
Specialist input sought (Seperate referral is required for each speciality)
*
Diabetes Mellitus Type 1
Diabetes Mellitus Type 2
Endocrinology
Gastroenterology/Endoscopy
General Medicine
Post-hospitalisation follow up
Geriatric Medicine
Haematology (Dr H. Tsuji only)
Heart Failure Nurse Practitioner (S. Clayden)
Nephrology/Renal Medicine
Neurology
Rheumatology
Stroke/TIA
Post-hospitalisation follow up: Team Colour
Green
Purple
Red
Gold
General Surgery
Requesting Consultant
Dr James Gome
Dr Reinhardt Dreyer
Dr Anna Clissold
Dr Hisashi Tsuji
Dr Atchu Paramanantham
Dr Mandri Dassanayke
Dr Sujatha Kamalaksha
Dr Meththa Herath
Dr Jonathan Fowler
Dr Martin Klein
Appointment urgency
Routine (next available)
Urgent
Referral
Please include as much information as possible (incomplete referrals will delay triage times)
How would you like to submit your referral?
*
Online form
Upload letter
Attach referral letter and relevant radiology and pathology results here
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Reason for referral
Allergies/Adverse reactions
Relevant past Medical History
Current management plan:
Medication List
Upload any relevant radiology and pathology results
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Are there any pending investigations? E.g. Echo/RFTs/pathology
Yes
No
Where have you requested these investigations?
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