REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
RENAL MEDICINE CLINIC

SEND TO Dr Dakshinamurthy Divi (Director of 
Renal Medicine) 
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 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 Divi

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.NOK Name
Next of Kin/Alternative Contact Ph: Patient Demographics.NOK Mobile Phone
Does patient identify as Aboriginal and/or Torres Strait Islander: Does pt identify as 
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 reason

Please provide provisional diagnosis (if available): Provisional diag

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

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.

E/LFT (serial measures where available): eLFT
FBC: FBC
Urine microscopy: Urine microscopy
Urine albumin: Urine albumin
Protein creatinine ratio (serial values if applicable): Protein creatinine
Ultrasound of kidneys: Ultrasound of kidney
Serial blood pressure readings: Serial blood pressur

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 Dakshinamurthy Divi (Director)	Dr Balaji Hiremagalur	Dr Jagadeesh Kurtkoti	
Dr Alan Parnham	Dr Sid Sharma	Dr Thomas Titus	

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