REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
GASTROENTEROLOGY CLINIC
Template for correspondence about patient with
OTHER CONDITIONS OR PRESENTATIONS

SEND TO Dr Russell Canavan (Director of Digestive Health)
Outpatient Access and Scheduling Centre
Fax: 07 5687 4497                          OR

Secure transmission service via Medical Objects, 
Healthlink to
QHEALTH, GOLD COAST HEALTH Outpatients
Outpatient Bookings and Referrals	From Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

Miscellaneous.Date

Dear Dr Canavan

SECTION 1 Patient details

RE: Patient Demographics.Full Name
DOB: Patient Demographics.DOB
AGE: Patient Demographics.Age

Gender: Patient Demographics.Gender
Address: Patient Demographics.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.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does the patient identify as Aboriginal and/or Torres Strait Islander: Does the pt identify
Interpreter required: Interpreter required
If yes, specify language: If yes, specify lang	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: Specify main reason 

Please provide provisional diagnosis (if available): Provisional diagnosi

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

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. 

Clinical Details.Result List (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.Problem List (Current) With Comments

Clinical Details.Problem List (Resolved) With Comments

Allergies: Clinical Details.Allergies

Current prescribed medications: Clinical Details.Medications - Current Regular

SMOs/VMOs in this Specialist Service	

Dr Russell Canavan (Director Digestive Health)	Dr Maneesha Bhullar	Dr Alicia Braund	
Dr John Edwards	Dr Natalie Funakoshi	Dr Naveed Ishaq	
Dr Sneha John (Director Endoscopy)	Dr Yon Xian Koh	Dr Tariq Masood	
Dr Hadi Moattar	Dr Michael Murray	Dr George Ostapowicz	
Dr Kash Sheikh	Dr Dheeraj Shukla	Dr Kevin Tang	
Dr Griff Walker			

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