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

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

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 Nagrani

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

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 

Does the patient have dentures: Dentures

Existing dental history: Dental history

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 Poonam Nagrani (Director)