REQUEST FOR COLPOSCOPY CLINIC APPOINTMENT - FAX 4215 1383
						       or E-REFER USING REFERRAL NET

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

Referral to:
Barwon Health Outpatient Colposcopy Clinic
Dr Anne Hotchin

Fax: 03 4215 1383

		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number
	
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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

		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: 

ATSI:   Patient Demographics.ATSI Status		DVA Number: Patient Demographics.DVA Number	
		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Health Insurance 	

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

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

Referral for Colposcopy if:
Pt tests positive for oncogenic HPV type 16 and/or 18:  + HVP type 16 & 18
Pt tests positive for non 16 or 18 oncogenic HPV type with:  +  non 16 & 18 with
Pt aged 70 to 74 with any positive oncogenic HPV type:  70-74 with + HVP 	

Reason for patient referral: 
Please arrange a colposcopy as per NHMRC guidelines
Other referral info	
Current Medication:
Clinical Details.Medications Current Regular	
Social History:
Clinical Details.Warnings
Clinical Details.Social History    
Clinical Details.Allergies  
 Clinical Details.Smoking
If yes to smoking, has cessation program been discussed?:  Smoking cessation 
 Clinical Details.Alcohol (Summary)	
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)