REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
EMERGENCY DEPARTMENT CLINIC

SEND TO Dr David Green (Director of Emergency Medicine)
Southport
Fax: 07 5687 4699    OR
Robina
Fax: 07 5668 6198

Please ensure ED is also notified by phone
Southport:  07 5687 5210
Robina:  07 5668 6100	FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

DO NOT send to OUTPATIENT ACCESS AND SCHEDULING CENTRE

<TodaysDate>

Dear Dr Green

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

No 'pre-requisite' information required however, please attach any investigation, result or correspondence you consider to be relevant.

<Ix>
SECTION 4 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 5 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 David Green (Director)