REQUEST FOR CARDIOLOGY CONSULTATION        			
Fax 4215 1990 or ReferralNet

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

For referral for Diagnostic services, please use Cardiology Diagnostic referral template 

Referral to:
Geelong Cardiology Practice 
Referring to:  Referring to:
Level 4
Kardinia House
University Hospital Geelong
Tel: 03 4215 1955
Fax:03  4215 1990

Urgency: Urgency
Referral valid for: Referral valid for		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
HPI-O:
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number
HPI-I:	

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
Pt IHI: Patient Demographics.IHI Number
ATSI:  Patient Demographics.ATSI Status
		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 	

Interpreter required: Interpreter required		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Interpreter language		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Health Insurance:  Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number	
TAC or Workcover: TAC or Workcover?		Refugee/Aslyum Seeker: Refugee/Asylum Pt?	

Date patient consented to referral:  Miscellaneous.Date	
Consent to share information:  Share information	
Consent to MBS bulk billing clinic:  MBS clinic	

Reason for referral:  Reason for referral

CLINICAL INFORMATION

Patient details:  Patient Demographics.Full Name  Patient Demographics.DOB

Is this a recurrent problem?: Recurrent problem?
Is this a 2nd referral for the same problem: 2nd ref same problem	
Previous relevant consultants or unit involved in Mx of problem or related problem:
Previous consultant	
Recent PHx Medication list review undertaken: 
Review PHx meds	
Warnings: Clinical Details.Warnings	
Allergies: Clinical Details.Allergies	

Current Medication:
Clinical Details.Medications Current Regular	
Social History:
Clinical Details.Social History  Clinical Details.Social History  Clinical Details.Alcohol (Summary)
Clinical Details.Smoking  
If smoker, has smoking cessation program been discussed?:  Smoking cessation	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Investigation Results:
Clinical Details.Result List (Selected)	

Signed: Dr

Treating Doctor.Name

Date: Miscellaneous.Date	

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