Victorian Statewide Referral Form	General Practice version Feb 2023

REQUEST FOR MEDICAL OUTPATIENT APPOINTMENT

Public OPD Service | Fax | ReferralNet
Chronic Viral Liver Disease (+ Hep C) | 4215 1383 | Yes
Dermatology | 4215 1383 | Yes
Endocrinology | 4215 1383 | Yes
Endoscopy - colonoscopy | 4215 1383 | Yes
Gastroenterology | 4215 1383 | Yes
General Medicine | 4215 1383 | Yes
General Medicine - Early Access Clinic Phone consultant before referral 0468 661 127 | 4215 1546 | No
IBD (Inflammatory Bowel Disease) | 4215 1383 | Yes
Infectious Diseases (+ refugee service) | 4215 1383 | Yes
Liver Mass Clinic | 4215 1383 | Yes
Respiratory (General / Chronic Lung Disease / Pulmonary Vascular Disease) | 4215 1383 | Yes
Sexual Health clinic (BRASH) | 4215 1383 | Yes
Cardiology (Public Clinics Only - Heart Failure / AF / Rhythm) | 4215 1990 | Yes
HITH (Phone medical officer before referral 0413 129 343) | 4215 1546 | No
Medical Day Stay (Iron Infusion) | 4215 2301 | No
Neurosciences (Public Clinic) | 4215 0757 | No
Renal (Public Clinic) | 4215 3595 | No

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

Referral to:
Barwon Health Outpatients

Service requested: <<Service Requested:>>
Urgency:  <<Urgency>>	

Referral valid for: 	<<Referral valid for>>

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

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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>>
Title:	<<Patient Demographics:Title>>
Pt IHI:                     <<Patient Demographics:IHI>>

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:

 
Interpreter required: <<Does the patient require an interpreter?>> | | DVA Number: <<Patient Demographics:DVA Number>>
Preferred language is: <<If interpreter needed, which language>> | | Insurance: <<Patient Demographics:Health Insurance>>
Pension Card Number: <<Patient Demographics:Pension Number>> | | Medicare Number: <<Patient Demographics:Medicare Number>>
TAC or Workcover? <<TAC or Workcover?>> | |

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 >>

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

HealthPathways provides guidance in State Referral Criteria, patient assessment, management and referral. 
 <<HealthPathways guidance in SRC Ax Mx  Referral>>

Reason for patient referral: 
<<Reason for Referral>>

<<BP?>>
<<Weight?>>

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Is this a recurrent problem?  <<Is this a recurrent problem?>>
Is this a second referral for the same problem?  <<Is this a 2nd referral for the same problem?>>
Previous relevant consultants or unit invloved in Mx of problem or related problem:
<<Previous consultant/s involved in Mx of problem>>
Recent PHx Medication list review undertaken:  <<Recent PHx Medication list review undertaken?>>

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

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

Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>> 

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

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

Social History: <<Clinical Details:Social History>> 
Smoking History:  <<Clinical Details:Smoking>>   
If yes to smoking, has cessation program been discussed?:  <<Smoking cessation program discussed?>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>

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