Referral Templates and Pre-Referral Guidelines

Referral Templates for Specialist Clinics:

• Best Practice Specialist Clinic Referral Form
• Zedmed Specialist Clinic Referral Form
• Medical Director Specialist Clinic Referral Form
• Specialist Clinics Referral Form

Please address all referrals to Dermatology Clinic to a named specialist - A/Prof Chris Baker (Head of Clinic)

Neurosurgery Referrals for Specialist Clinics:

Please refer to the Neurosurgery Referral Guidelines for further information.

Please see here for Exclusion Criteria. 

• Spinal Assessment and Management Service Referral Form - 
  As of the 23rd September 2019, all spinal referral will require this form.

Oro Maxillo Facial Referrals

The Maxillofacial Surgery Unit provides a complete range of specialist oral and maxillofacial surgical care for patients with facial trauma, benign and malignant oral pathology, facial deformity, and TMJ disorders.

We are not able to offer tooth extractions (including wisdom teeth) or other dental procedures under general anaesthetic except in the setting of patients with significant medical co-morbidities.

Endoscopy Referral Templates for Gastroenterology / Colorectal / Upper Gastrointestinal Surgery Clinics:

Referrals for patients likely to require endoscopy must be made using the templates below:

• Gastroenterology/Colorectal/Upper Gastrointestinal Referral to Clinics - Best Practice
• Gastroenterology/Colorectal/Upper Gastrointestinal Referral to Clinics - Medical Director
• Gastroenterology/Colorectal/Upper Gastrointestinal Referral to Clinics - ZedMed
• Endoscopy referral form (paper): Gastroenterology/Colorectal/Upper Gastrointestinal Referral to Clinics

Please visit Endoscopy website for further information

Referral Templates for Hepatitis C Treatment Request:

• Hepatits C Treatment - Best Practice
• Hepatits C Treatment - Medical Director
• Hepatits C Treatment - ZedMed
• Hepatitis C Treatment - Genie
• Primary Care Consultation Request - Hepatitis C Treatment

Referrals to Palliative Care:

Please FAX a referral letter to: (03) 9231 4143

For more information on palliative care outpatient appointments Tel: (03) 9231 2827 

Referrals to Breast Clinic:

Breast Clinic Referral Guidelines

Please FAX referral form to: (03) 9231 2017

For enquiries, please phone: (03) 9231 4743 Email: BreastNurseCoOrdinator@svha.org.au

Referrals to Lymphoedema Service:

Lymphoedema Service referral form

Please FAX referral form to: (03) 9231 3489

For enquiries/urgent referrals, please phone: (03) 9231 1971 (Tuesdays & Wednesdays)

Obesity Management Clinic:

• Please FAX referrals to: (03) 9231 3590
• >Referral criteria: BMI > 35kg/m2 with medical co-morbidities that will improve with weight loss

Referral Templates for Community and Aged Care Services:

• Best Practice Specialist Clinic Referral Form
• Zedmed Specialist Clinic Referral Form
• Medical Director Specialist Clinic Referral Form
• Specialist Clinics Referral Form

This referral template is for the following services:

• Aged Psychiatry Assessment and Treatment Team (APATT)
• Community Rehabilitation Centres
• HARP (Hospital Admission Risk Program)
• Home-Based Allied Health
• Polio Services Victoria
• Young Adults Complex Disability Service
• Specialist Clinics - Continence Clinic, Cognitive Dementia and Memory Clinic, Geriatric Medical Clinic, Falls and Balance Clinic, Pain Clinic for Older Persons

Referral Template for inter-hospital referral to Sub Acute Ambulatory Care Services (SACS):

• Health Independence Programs Referral Form

Please Note: This referral form is for inter-hospital use only and not for referrals from General Practice