REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
GENERAL SURGERY CLINIC
Template for correspondence about patient with
HERNIA(E)

SEND TO Dr Michael Von Papen (Director of General Surgery)
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 Von Papen

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 Mandatory clinical information

Any irreducible or partially reducible hernia: <Any irreducible/partially reducible hernia>
If yes, please specify: <If yes, specify hernia reducibility details>
Symptomatic hernia impacting on daily life: <Symptomatic hernia impacting daily life>
If yes, please specify:<If yes, specify hernia impacting daily life details>

SECTION 4 Investigations

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

<Ix>
SECTION 5 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 6 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 7 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 Michael Von Papen (Director)	Dr Rafid Alzubaidy	Dr Mark Doudle	
Dr Jason Free	Dr John Gault 	Dr Roger Khan	
Dr Rhea Liang 	Dr Cu Tai Lu	Dr David Mackrill	
Dr Arun Naik	Dr Greg B.Nolan	Dr Greg J. Nolan	
Dr David Parker	Dr Harald Puhalla	Dr Leigh Rutherford	
Dr Craig Sommerville			

 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