General Practice Referral Template Page 2
ADVERTISEMENT
1
2Consumer
General practice referral
Name:
Purpose: to provide a standardised quality
Date of Birth: dd/mm/yyyy
/
/
referral from general practice to other
Sex:
service providers
UR Number:
or affix label here
Clinical information
Warnings:
Allergies:
Current medication:
None known:
Drug name
Strength
Dose/frequency/special
Social history:
Medical history:
Investigation / Test results / Relevant plans (eg General Practice Management Plan, Team Care Arrangement,
Mental Health Treatment Plan):
Referral Acknowledgment:
to be completed by agency/practitioner in receipt of referral
To acknowledge a referral you have received, complete this section
From
Name:
Position:
Organisation:
Phone:
Email:
Fax:
To
Name:
Position:
Organisation:
Phone:
Email:
Fax:
Date referral received: dd/mm/yyyy
/
/
Status of referral:
Accepted
Wait listed
Rejected (note reason and suggested alternatives)
Estimated date of assessment: dd/mm/yyyy
/
/
Contact person for further information:
As above (From details)
New contact (Provide in notes)
I agree to participate in the care of this patient under a Team Care Arrangement
Notes:
Referring doctor
Patient name:
Date: dd/mm/yyyy
/
/
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Life