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.Gender
UR Number: 
Referral date: Miscellaneous.Date	

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: Patient Demographics.Popular Name
Date of Birth: Patient Demographics.DOB	Sex: Patient Demographics.Gender	Title: Patient Demographics.Title
Address: Patient Demographics.Full Address
Phone: Patient Demographics.Phone (Home)	Work: Patient Demographics.Phone (Work)	Mobile: Patient Demographics.Phone (Mobile)
Email:Patient Demographics.E-mail	Alternative contact: 	Indigenous status: 	

Interpreter required: Yes  No 
Preferred language:
		DVA number: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund Name Number: Patient Demographics.Health Fund Member Number
Medicare number: Patient Demographics.Medicare Number	

Referring General Practitioner
Name: 	Treating Doctor.Name
Address: 	Practice.Address
Phone: 	Practice.Phone
Fax: 	Practice.Fax
Provider number: 	Treating Doctor.Provider Number	

Specialist Clinic requested

	

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

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.Gender
UR Number: 
Referral date: Miscellaneous.Date	

Clinical information

Medical past  history: 
Clinical Details.Problem List (Current) With Comments, Onset Year

Please attach relevant investigations. Name of pathology provider

	

Current medications:	
Clinical Details.Medications - Current Regular	

Warnings
Clinical Details.Warnings

Allergies
Clinical Details.Allergies

Social history
Clinical Details.Social History