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:  Patient Demographics.Full Name
Date of Birth:  Patient Demographics.DOB 
Sex:  Patient Demographics.Gender
UR Number:  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	Title:  Patient Demographics.Title	
Preferred name/s: Preferred name	Date of Birth:  Patient Demographics.DOB	
Address:  Patient Demographics.Address, Patient Demographics.Suburb   Patient Demographics.Postcode	Sex:  Patient Demographics.Gender	
Phone:  Patient Demographics.Phone (Home)	Work:  Patient Demographics.Phone (Work)	Mobile:  Patient Demographics.Phone (Mobile)	
Alternative contact:  Patient Demographics.Emergency Contact Mobile Phone	
Indigenous status:  Indigenous Status	

Interpreter required:  Interpreter required		DVA number:  Patient Demographics.DVA Number	
Preferred language:  Preferred Language		Insurance:  Patient Demographics.Health Fund Name	
Pension card number:  Patient Demographics.Pension Number		Medicare number:  Patient Demographics.Medicare Number	

Referring General Practitioner
Name:  Treating Doctor.Name	
Address:  Treating Doctor.Address, Treating Doctor.Suburb   Treating Doctor.Postcode>	
Phone:  Treating Doctor.Phone	
Fax:  Treating Doctor.Fax	
Provider number:  Treating Doctor.Provider Number	

Specialist Clinic requested
Specialist Clinic	

Reason for patient referral (please clearly specify reason for referral)
Reason for 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:  Patient Demographics.Full Name
Date of Birth:  Patient Demographics.DOB 
Sex:  Patient Demographics.Gender
UR Number:  UR Number
Referral date:  Miscellaneous.Date	

Clinical information (please attach relevant investigations and name of pathology provider)
Medical past  history:
Clinical Details.Past History	

Current medications:
Clinical Details.Medications - Current PRN

Clinical Details.Medication List	

Warnings:
Clinical Details.Warnings	

Allergies:
Clinical Details.Allergies	

Social history
Clinical Details.Social History	

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