Western Health
General practice referral

Adult Specialist Clinics 
Ph 8345 6490   Fax 8345 6856

Women’s Clinic
(maternity and gynae)  AND 
Paediatric Specialist Clinics 
Ph 8345 1727   Fax 9055 2125
		Patient
Name:  <PtName>
Date of Birth:  <PtDoB> 
Sex:  <PtSex>
UR Number:  <UR Number>
Referral date:  <TodaysDate>	

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:  <PtName>	Title:  <PtTitle>	
Preferred name/s: <Preferred name/s>	Date of Birth:  <PtDoB>	
Address:  <PtStreet>, <PtCity>   <PtPostcode>	Sex:  <PtSex>	
Phone:  <PtPhoneH>	Work:  <PtPhoneWk>	Mobile:  <PtPhoneMob>	
Alternative contact:  <Alternative contact>	
Indigenous status:  <Indigenous Status>	

Interpreter required:  <Interpreter required>		DVA number:  <PtDVANo>	
Preferred language:  <Preferred language>		Insurance:  <PtHealthIns>	
Pension card number:  <PtPensionNo>		Medicare number:  <PtMCNo>	

Referring General Practitioner
Name:  <DrName>	
Address:  <DrStreet>, <DrCity>   <DrPostcode>	
Phone:  <DrPhone>	
Fax:  <DrFax>	
Provider number:  <DrProviderNo>	

Specialist Clinic requested
<Specialist Clinic requested>	

Reason for patient referral (please clearly specify reason for 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)  AND 
Paediatric Specialist Clinics 
Ph 8345 1727   Fax 9055 2125
		Patient
Name:  <PtName>
Date of Birth: <PtDoB>
Sex:  <PtSex>
UR Number:  <UR Number>
Referral date:  <TodaysDate>	

Clinical information (please attach relevant investigations and name of pathology provider)
Medical past  history:
<SelectedPMH>	

Current medications:
<SelectedRx>	

Warnings:
<Comment>	

Allergies:
<Reactions>	

Social history
<SocialHx>	

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