REQUEST FOR MEDICAL SPECIALIST CLINIC APPOINTMENT (PUBLIC CLINICS ONLY)

Public Specialist Clinic/Service	Fax	ReferralNet	
Chronic Viral Liver Disease (+ Hep C)	4215 1383	BH.Outpatients	
Dermatology 	4215 1383	BH.Outpatients	
Endocrinology	4215 1383	BH.Outpatients	
Endoscopy - gastroscopy / colonoscopy (not open access)	4215 1383	BH.Outpatients	
Gastroenterology	4215 1383	BH.Outpatients	
General Medicine	4215 1383	BH.Outpatients	
IBD (Inflammatory Bowel Disease)	4215 1383	BH.Outpatients	
Infectious Diseases (+ refugee service)	4215 1383	BH.Outpatients	
Liver Mass Clinic	4215 1383	BH.Outpatients	
Respiratory (General / Chronic Lung Disease / Pulmonary Vascular Disease)	4215 1383	BH.Outpatients	
			
General Medicine - Early Access Clinic 
(Phone consultant before referral 0468 661 127)	4215 1546	No	
Hospital in the Home ( Phone Medical Officer before referral- 0413 129 343)	4215 1546	No	
Sexual Health Clinic (BRASH clinic- UHG & Barwon Health North) 	4215 1366	No	
Cardiology (Public Clinics - Heart Failure / AF / Rhythm)	4215 1990	Geelong.Cardiology	
Neurosciences (Public Clinic)	4215 0757	No	
Renal (Public Clinic) 	4215 3595	No	
Medical Day Stay (Iron infusions)	4215 2301	No	

GP Referral
		Referral Date: <TodaysDate>
Feedback Requested:  Yes

Referral to:
Barwon Health Specialist Clinics- Medical

Service requested: <Service Requested:>

Urgency:  <Urgency>		
Referral valid for: <Referral valid for>
		Referring General Practitioner:
Name:<DrName> 
Practice: <Practice> 
Address:<UsrAddress>
Phone: <UsrPhone>   
Fax:  <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>	

Patient/Client/Consumer details:
Title: <PtTitle>
First name: <PtFirstName> 
Surname: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>   Age: <PtAge>
Sex at Birth: <PtSex>
Gender Identity: <GenderIdentity>
ATSI: <PtEthnicity>

Interpreter required: <Does the patient require an interpreter?>
Preferred language is: <If interpreter needed, which language>
Please consider Telehealth for this patient:
<Please consider Telehealth for this patient:>
Cultural safety requirements: <Cultural safety requirements?>
Access/Support requirements: <Access/Support requirements?>		Address: <PtAddress>
Mobile: <PtPhoneMob>
Email: <PtEmail>
Home Phone: <PtPhoneH>  
Work Phone: <PtPhoneWk>
Preferred method of communication: <Patient's preferred contact method>

Medicare: <PtMCNo> <PtMCLine> Expiry: <PtMCExpiry>
Pension/HCC: <PtPensionNo>
DVA: <PtDVANo>
Insurance: <PtInsFund> <PtInsNo>

NOK/Carer/Alternate contact:
Name: <NOKName>  Phone: <NOKContact>
Relationship: <NOKRelation>

	

Consent to referral: <Consent to referral>  
Consent to share information: <Consent to share information>
Is this a 2nd referral for the same problem: <Is this a 2nd referral for the same problem?>
Usual GP (if not referrer):  <Usual GP (if different to referrer)- Name/Practice>	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Ax Mx referral>
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
<Statewide Referral Criteria apply for Specialist Clinics Referrals.>	

Reason for referral:
<Reason for referral>

Previous consultant involved in management of this condition: 
 <Previous consultant involved in the Mx of this condition>

Observations:
Height: <Height>	Weight: <Weight>	BMI: <BMI>	

Investigation Results:  <Please add relevant results only>
Pathology provider:  <Which provider was used for pathology?>
Radiology provider:  <Which provider was used for radiology?>
Investigations:
<Ix>
Investigations ordered today:  <Investigations ordered today?>

Past Medical History:
<PMHActive>

Social History:
<SocialHx>

Family History:
<FamilyHx>

Current Medications:
<CurrentRx>

Alerts:
<Comment>

Allergies:
<Reactions>

Alcohol History:
<AlcHx>

Smoking Status:
<SmkStatus>
If smoker, smoking cessation discussed: <If smoker, smoking cessation discussed?>

Electronically signed:  <DrName>