Victorian Statewide Referral Form	General Practice version Feb 2022

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

GP Referral | | Referral Date: <<Miscellaneous:Date (long)>> Feedback Requested:  Yes

Referral to:
Barwon Health Outpatient Colposcopy 
Dr Anne Hotchin

Fax: 03 4215 1383

Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>

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Consumer details:
Name:<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
ATSI:               <<Patient Demographics:ATSI>>    
Title:	<<Patient Demographics:Title>>

Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>

Alternative Contact:

Pension Card Number: <<Patient Demographics:Pension Number>> | | DVA Number: <<Patient Demographics:DVA Number>>
Medicare Number: <<Patient Demographics:Medicare Number>> | | Insurance: <<Patient Demographics:Health Insurance>>

Date patient consented to referral:   <<Miscellaneous:Date (short)>>
Consent to share information:  <<Consent to share information>>
Consent to MBS bulk billing clinic if available:  <<Consent to MBS bulk billing clinic if available>>

Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>>

Social Hx: <<Clinical Details:Social History>> 
Smoking Hx: <<Clinical Details:Smoking>>       
If smoker, has cessation program been discussed?:  <<If smoker, has cessation program been discussed?>>

Clinical Information:		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>>

Referral for Colposcopy if: 
Pt tests positive for oncogenic HPV  16 and/or 18:  <<Positive for oncogenic HPV 16 and/or 18>>
Pt tests posititive for non 16 or 18 oncogenic HPV  type with:  <<Non 16 or 18 oncogenic HPV  type with>>
Pt aged 70 to  74 with any oncogenic HPV type:  <<Pt aged 70 - 74 with any oncogenic HPV  type>>

Reason for patient referral: 

Referral Criteria:
Please arrange a colposcopy as per NHMRC guidelines
<<Other Information for Referral>>

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

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

Progress Notes: 
<<Summary:Progress Notes (Selected)>>

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

HealthPathways WestVic provides guidance in patient assessment, management and referral. 	<<HealthPathways WestVic guidance in AxMx referral>>

GP Referral:  <<Doctor:Name>>,  Patient: <<Patient Demographics:Full Name>>,  <<Miscellaneous:Date>> 	Page