REQUEST FOR CONSULTATION
CORE SURGERY 

SEND TO: 
 Dr Vasant Rajan, Core Surgery

OR

Fax: 07 3245 7530	FROM <<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider Number: <<Doctor:Provider Number>>

<<Miscellaneous:Date (long)>>

Dear Doctor

<<Specialty / Doctor>>

Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
AGE: <<Patient Demographics:Age>>

Gender: <<Patient Demographics:Sex>>
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)
Medicare Expiry: <<Patient Demographics:Medicare Expiry Date>>
DVA Number: <<Patient Demographics:DVA Number>>
DVA Expiry: <<DVA expiry>>	Next of Kin/Alternative Contact: <<Patient Demographics:Next of Kin>>
Next of Kin/Alternative Contact Ph: <<Patient Demographics:Next of Kin Phone>>
Does patient identify as Aboriginal and/or Torres Strait 
Islander: <<Patient Demographics:ATSI>>
Interpreter required: <<Interpreter required>>
If yes, specify language: <<If yes, specify language>>
Patient suitable for telehealth if available: <<Patient suitable for telehealth if available>>	

Reason for referral

Reason for referral: <<Specify main reason for referral>>

Please indicate how long you would like the referral to remain valid:  <<Duration of referral>>

Investigations

<<Summary:Investigation Results (Selected)>>

Medical history

Past medical history: <<Clinical Details:History List>>

Allergies:  <<Clinical Details:Allergies/Adverse Reactions>>

Current prescribed medications: <<Clinical Details:Medication List>>

Smoking: <<Clinical Details:Smoking>>

Alcohol: <<Clinical Details:Alcohol>>