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	

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
                   Patient Demographics.Health Fund Member Number	
Pension card number:  Patient Demographics.Pension Number		Medicare number:  Patient Demographics.Medicare Number	

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

Duration of referral:  Duration of referral	

Specialist Clinic requested
Specialist Clinic requested: Specialist clinic 	

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
Referral date:  Miscellaneous.Date	

Reason for Referral - Please provide detailed description
Reason for referral
Reason for referral

Clinical information (please attach relevant investigations and name of pathology provider)
Medical past  history:
Clinical Details.Problem List (Current)
Clinical Details.Problem List (Resolved)	

Current medications:
Clinical Details.Medication List

Warnings:
Clinical Details.Warnings	

Allergies:
Clinical Details.Allergies	

Social history
Clinical Details.Social History
Clinical Details.Family History
Clinical Details.Alcohol	

Investigations
Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name Practice.Name