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: <<Miscellaneous:Date (short)>>
Feedback Requested:  <<Feedback requested>>	

Referral to:
Barwon Health Specialist Clinics- Medical

Service requested  <<Service Requested:>>

Referral Urgency: <<Referral Urgency>>
Referral valid for: <<Referral valid for>>		Referring General Practitioner:
Name:<<Doctor:Name>>
Practice: <<Practice/Location:Name>>
Address:<<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>  
Fax:  <<Practice/Location:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>	

Patient/Client/Consumer details:
Title: <<Patient Demographics:Title>>
First name: <<Patient Demographics:First Name>>
Surname: <<Patient Demographics:Surname>>
Preferred Name: <<Patient Demographics:Known As>>
Date of Birth: <<Patient Demographics:DOB>>  Age: <<Patient Demographics:Age>>
Gender: <<Patient Demographics:Gender>>
ATSI: <<Patient Demographics:ATSI>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Preferred language is: <<Patient Demographics:Language Spoken>>
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: <<Patient Demographics:Address>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Home Phone:  <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Preferred method of communication: <<Patient preferred contact method>>

Medicare: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension/HCC: <<Patient Demographics:Pension Number>>
DVA: <<Patient Demographics:DVA Number>>
Insurance: <<Patient Demographics:Health Insurance>>

NOK/Carer/Alternate contact:
Name: <<Patient Demographics:Next of Kin>> 
Phone: <<Patient Demographics:Next of Kin Phone>>
Relationship: <<Patient Demographics:Next of Kin Relationship>>

Consent to referral: <<Consent to referral?>> 
Consent to share information: <<Consent to share information?>>
Consent to contact from service: <<Consent to contact from service?>>
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 Clinic>>	

Reason for referral:
<<Reason for referral>>

Previous relevant consultants or unit invloved in Mx of problem or related problem:
<<Previous consultant/s involved in Mx of problem>>

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

Investigation results: <<Please add relevant results only>>
Pathology: <<Which provider was used for pathology?>>
Radiology: <<Which privider was used for radiology?>>
Investigatios:
<<Summary:Investigation Results (Selected)>>
Investigations ordered today: <<Investigations ordered today?>>

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

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

Family History:
<<Clinical Details:Family History>>

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

Alerts:
<<Clinical Details:Warnings>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Alcohol History:
<<Clinical Details:Alcohol>>

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

Smoking Status:
<<Clinical Details:Smoking>>

If smoker, smoking cessation discussed: 
<<If smoker, smoking cessation discussed?>>

Electronically signed: <<Doctor:Name>>