For your referral request to be accepted and clinically prioritised we need the following information.
Patient demographic information
full name
date of birth
birth sex
gender identity
address
telephone number(s)
email address
alternative contact details
preferred method of communication
Medicare number (if eligible)
if a person identifies as being of Aboriginal or Torres Strait Islander origin
any requirements to ensure cultural safety (including family violence safety)
language other than English (if applicable), reliance on a carer, reliance on cultural, linguistic or disability support (for example, need for an interpreter), reliance on transport or accommodation support
name of parent or carer (if applicable)
medical treatment decision-maker, support person or carer (if any)
contact details for usual GP (if the GP is not the referring clinician)
Referrer demographic information
Required referral information
Required referral information:
date of referral
indication if the patient has agreed to the referral and the sharing of their personal and health information with the health service
referring clinician’s assessment of clinical urgency (urgent or routine)
required clinical information listed in any referral criteria for the presenting problem
Service requested
Indicate the specialist clinic or service requested.
Reason for referral
If the main purpose of the referral is:
requesting services to establish a diagnosis, provide clinical assessment or inform a treatment plan
requesting partnership care between the patient, GP and the health service (such as patients with chronic or progressive conditions who require ongoing specialist advice or services to improve and optimise people’s function and participation in activities of daily living)
requesting specific tests or investigations that cannot be ordered, accessed or interpreted through the primary care system
requesting treatments or an intervention.
Presenting problem
Indicate the presenting problem or working diagnosis and if the patient has received earlier services for the same presenting problem.
Current patient management
Summary of current patient management including:
current treatment
previous treatment and response to this treatment
complete and current medication list
allergies and previous adverse events
relevant medical history including any functional or cognitive impairment
relevant family history
relevant physical, psychosocial and structural barriers the person experiences which may impact on their access to services
existing community supports (if any)
existing advance care directive (if any).
Impact of the problem on the patient
List any functional impairments, impact on work, study or school, impact on caring responsibilities, social impact, impact on comorbidities and any other impact on the person’s quality of life.
About the minimum referral information requirements
The Victorian Government's policy for Managing referrals to non-admitted specialist services in Victorian public health services sets the minimum referral information requirements. For further information on the policy, see here
