St Vincent's Clinics Referral Form
Fax to Clinic Appointment Triage on 9231 3489
If urgent phone the relevant Clinic Care Coordinator on 9231 2898
For referrals to CancerClinic, fax to 9231 3172
For referral to Barber Walker Centre for Pain Management, fax to 9231 4660
DO NOT USE THIS FORM FOR PATIENTS YOU THINK REQUIRE ENDOSCOPY. Instead see
https://svhm.org.au/home/health-professionals/specialist-clinics/e/endoscopy/referral-information-for-doctors
Date: Miscellaneous.Date
Patient Details
Patient Demographics.Full Name
Patient Demographics.Full Address
Phone: Patient Demographics.Phone (Home)
Mob: Patient Demographics.Phone (Mobile)
Date of Birth: <<Patient Demographics:DOB>>
Medicare No.: Patient Demographics.Medicare Number
St Vincent's UR (if known) St V Hospital UR No
Clinic Required: (select clinic) Clinic Required
Patient has attended this Clinic before Pt attended clinic
Interpreter Required Interpreter Required
If yes, which language? language select
Other language if not listed Other language
Urgency Urgency
Reason for Referral
(Please include significant symptoms, signs, duration and investigation reports.
Remember! The Appointment will be prioritised on the clinical information and investigation reports you provide)
Reason for Referral
Relevant Past Medical History
Clinical Details.Past History
Current Medications
Clinical Details.Medications - Current PRN
Allergies
Clinical Details.Allergies
Relevant Investigation Reports
Clinical Details.Result List (Selected)
Signature:
Treating Doctor.Name Provider Number: Treating Doctor.Provider Number
Practice.Name
Practice.Address
Ph: Practice.Phone Fax: Practice.Fax
Referral Valid for: Referral Valid for
GPs please note:
Ensure your practice details are up-to-date in the National Health Services Directory.
We rely on this to send letters about your patient’s care.
To update: Phone: (02) 9263 9092 or email: nhsd@healthdirect.org.au
Please consult HealthPathways Melbourne
http://melbourne.healthpathways.org.au
for assessment, management and referral guidance on clinical presentations
Username: connected / Password: healthcare