Western Health 
General practice referral

Adult Specialist Clinics 
Ph 8345 6490   Fax 8345 6856

Women’s Clinic
(maternity and gynae)
Ph 8345 1727   Fax 8345 1691

Paediatric Specialist Clinics
Ph 83451616  Fax 8345 1079		Patient
Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Sex>>
UR Number: <<UR Number>>
Referral date: <<Miscellaneous:Date (short)>>	

Please refer to Melbourne HealthPathways at http://melbourne.healthpathways.org.au for guidance in assessing, managing and referring for patient conditions.

Referrals that do not include adequate information for triaging, including the required minimum investigations as per the HealthPathways and www.westernhealth.org.au will be returned with a request for further information.

Patient details
Name: <<Patient Demographics:Full Name>>	Preferred name/s: <<Preferred Name>>
Date of Birth: <<Patient Demographics:DOB>>	Sex: <<Patient Demographics:Sex>>	Title: <<Patient Demographics:Title>>
Address: <<Patient Demographics:Address>>
Phone: <<Patient Demographics:Phone (Home)>>     	Work: <<Patient Demographics:Phone (Work)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>	Alternative contact: <<Alternative contact>>	Indigenous status: <<Patient Demographics:Ethnicity>>	

Interpreter required: <<Interpreter required>>
Preferred language: <<Patient Demographics:Language Preferred>>
Pension card number: <<Patient Demographics:Pension Number>>		DVA number: <<Patient Demographics:DVA Number>>
Insurance: <<Patient Demographics:Health Insurance>>
Medicare number: <<Patient Demographics:Medicare Number>>	

Referring General Practitioner
Name: 	<<Doctor:Name>>
Address: 	<<Doctor:Address>>
Phone: 	<<Doctor:Phone>>
Fax: 	<<Doctor:Fax>>
Provider number: 	<<Doctor:Provider Number>>	

Specialist Clinic requested
<<Specialist Clinic requested>>

Referral duration
¨  12 months	¨  Indefinite referrals (recommended for ongoing chronic conditions)

Reason for patient referral
<<Reason for patient referral>>

Western Health 
General practice referral

Adult Specialist Clinics 
Ph 8345 6490   Fax 8345 6856

Women’s Clinic
(maternity and gynae)
Ph 8345 1727   Fax 8345 1691

Paediatric Specialist Clinics
Ph 83451616  Fax 8345 1079		Patient
Name: <<Patient Demographics:Full Name>>
Date of Birth: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Sex>>
UR Number: <<UR Number>>
Referral date: <<Miscellaneous:Date (short)>>	

Clinical information

Medical past  history: 
<<Clinical Details:History List>>

Please attach relevant investigations. Name of pathology provider

	

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

Warnings
<<Clinical Details:Warnings>>

Allergies
<<Clinical Details:Allergies/Adverse Reactions>>

Social history
<<Clinical Details:Social History>>