REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
CARDIOLOGY CLINIC

SEND TO Dr Rohan Jayasinghe (Director of Cardiology)
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                           OR

Secure Transmission Service via Medical Objects or Healthlink to:
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Jayasinghe

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>
AGE: <PtAge>

Gender: <PtSex>
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/Alternative Contact Ph: <NOKContact>
Does patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>

Please provide provisional diagnosis (if available): <Provisional diagnosis if available>

Please include any symptoms and date of onset (if known): <Symptoms and date of onset if known>

Paste or type relevant history, clinical examination findings and treatment to date if required

SECTION 3 Investigations

Please indicate whether the following pre-requisite investigations have been undertaken in order for this referral to be processed and attach the results. In addition, please also attach any investigation results you consider to be relevant, such as: any previous angiogram reports, CABG reports, echo reports, ECG and relevant letters from previous managing Cardiologists. 

	FBC: <FBC>
	E/LFTs: <E/LFTs>
	Recent cardiac investigations: <Recent cardiac investigations>

<Ix>

SECTION 4 Duration of referral

Please indicate how long you would like your referral to remain valid: <Duration of referral>

Indefinite referrals do not expire until the patient has been discharged by the hospital service. When referrals expire, there is an expectation that the referring GP or another GP will review the care of the patient. If the patient still requires specialist care, the GP will then be required to submit a new referral for ongoing care. 

SECTION 5 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.

SECTION 6 Medical history including co-morbidities and previous surgical interventions

Alcohol: <AlcHx>

Smoking: <SmkStatus> <SmkHx>

<PMHAll>

Allergies: <Reactions>

Current prescribed medications: <CurrentRx>

SMOs/VMOs in this Specialist Service

Dr Rohan Jayasinghe (Director)	Dr Ian Agahari	Dr Greg Aroney	
Dr Ravinder Batra	Dr Jonathan Chan	Dr Nasser Essack	
Professor Laurie Howes	Dr Vijay Kapadia	Dr Selva Niranjan	
Dr Robert Park	Dr Atifur Rahman	Dr Kulijit Singh	

 General information about referrals

Queensland Clinical Prioritisation Criteria (CPC) are available for this condition and specialty. These criteria can be viewed by visiting: https://cpc.health.qld.gov.au/

Referral Templates that outline clinical information and investigations required to safely refer your patient into Gold Coast Health can be accessed via: https://www.healthygc.com.au/Health-Care-Professionals/Referral-Templates.aspx