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 to:
Barwon Health Specialist Clinics- Medical

Service requested: Service requested
Referral Urgency: Referral Urgency
Referral valid for: Referral valid for
_______________________________
Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number
___________________________________________
Address: Patient Demographics.Full 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: Preferred contact 
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 Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

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

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
Referral criteria	

Reason for referral:
Reason for referral

Previous consultant involved in the management of this condition:
Previous consultant

Observations:
Height:Current Measurements.Physical - Height
Weight:Current Measurements.Physical - Weight
BMI:Current Measurements.Physical - Body Mass Index

Relevant results
Pathology provider:  Pathology
Radiology Provider: Radiology
Investigation Results:
Clinical Details.Result List (Selected)

Past Medical History:
Clinical Details.Past History

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

Alcohol History:
Clinical Details.Alcohol

Smoking Status:
Clinical Details.Smoking
If smoker, smoking cessation discussed: Smoking cessation

Electronically signed by: Treating Doctor.Name