Western Health
General practice referral 
(version 1)
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 (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>>	Title:  <<Patient Demographics:Title>>	
Preferred name/s: <<Preferred name/s>>	Date of Birth:  <<Patient Demographics:DOB>>	
Address:  <<Patient Demographics:Address>>, <<Patient Demographics:City>>   <<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 Phone>>	
Indigenous status:  <<Indigenous Status - select from drop down list>>	

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

Duration of Referral
Duration of referral: <<Duration of referral - select from drop down list>>

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

Specialist Clinic requested
<<Specialist Clinic - select from drop down list>>	

Western Health
General practice referral
(version 1)
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 (short)>>	

Reason for patient referral (please clearly specify reason for referral)
<<Reason for patient referral>>	
Clinical information (please attach relevant investigations and name of pathology provider)
Medical past  history:
<<Clinical Details:History List>>	

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

Warnings:
<<Clinical Details:Warnings>>	

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

Social history
<<Clinical Details:Social History>>
<<Clinical Details:Family History>>	

Investigations
<<Summary:Investigation Results (Selected)>>

Electronically signed by: <<Doctor:Name>> <<Practice/Location:Name>>