REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
NEUROSURGERY CLINIC
Template for correspondence about patient with
VASCULAR DISORDERS (ANEURYSMS, ARTERIO-VENOUS MALFORMATIONS)

SEND TO Dr Teresa Withers (Director of Neurosurgery)
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 <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Dr Withers

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Gender>>
Address: <<Patient Demographics:Full Address>>
Home Ph: <<Patient Demographics:Phone (Home)>>
Mobile Ph: <<Patient Demographics:Phone (Mobile)>>
Medicare Number*: <<Patient Demographics:Medicare Number>>   (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
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: Family history of aneurysm or AVM.

CT/ CTA and/or MRI results: <<CT/CTA and/or MRI results>>

<<Summary:Investigation Results (Selected)>>

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: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>

<<Clinical Details:History List>>

<<Operation:CoMorbidities>>

<<Operation:Previous Procedures>>

Allergies: <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

SMOs/VMOs in this Specialist Service

Dr Teresa Withers (Director)	Dr Ashish Jonathan	Dr Wayne Ng	
Dr Paul Poulgrain	Dr Christian Schwindack	Dr Ellison Stephenson	
Professor Marianne Vonau	Dr Liqun Yang		

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