REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
ORAL HEALTH CLINIC
Template for correspondence about patient with
DENTAL HEALTH ISSUES

To be eligible for services provided by Queensland Health - Oral Health patients must have concession entitlements e.g. Pension/Concession care, DVA card or Commonwealth Senior's Card

SEND TO  Dr Poonam Nagrani (Director)
Oral Health Bookings Office

Please fax completed referrals to:
Fax: 07 5680 9590    OR    Phone: 1300 300 850

FROM <DrName>
<Practice>
<UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Nagrani

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

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.

Management provided to date: <Management provided to date> 	

Does the patient have dentures: <Does the patient have dentures>

Existing dental history: <Existing dental history>

<Ix>
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: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
<PMHAll>
Allergies: <Reactions>
Current prescribed medications: <CurrentRx>
SMOs/VMOs in this Specialist Service

Dr Poonam Nagrani (Director)