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Collects mandatory patient demographics, identity and communication preferences, Medicare and insurance identifiers, interpreter and Aboriginal status information, and contact person details. Captures referral specifics such as requested specialist, presenting problem or working diagnosis, current management, investigations and medication status, allergies, alerts or risks, medical history, and additional considerations. Includes referring practitioner information, referral date, provider number, referral period, copies, and usual GP confirmation. Missing required details may delay processing or result in refusal.",{"@graph":63,"@context":122},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/referral-to-specialist-outpatient-clinics-patient-referral-form/280992/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/referral-to-specialist-outpatient-clinics-patient-referral-form/280992.png","ImageObject",442,249,{"name":88,"@type":89},"Alex Sinclair","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-27","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114,118],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required from the patient for this referral?","Question",{"text":108,"@type":109},"The form collects mandatory patient demographics, contact details, sex/gender identity, address and telephone, Medicare and other identifiers, interpreter needs, and Aboriginal status. It also requests contact person information and preferred contact method.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What clinical details must be included for the referral to be accepted?",{"text":113,"@type":109},"The referral must specify the requested specialist clinic and include the reason for referral, presenting problem or working diagnosis, and current management with response to treatment. It also requests key attachments such as relevant investigations or histopathology and a medication list if applicable.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the form handle investigations, medications, allergies, and medical history?",{"text":117,"@type":109},"Sections allow listing investigations and results (or indicating none/attachments), documenting medications (or indicating none/attachments), recording allergies, and noting alerts or risks. Medical history options and additional considerations are also captured.",{"name":119,"@type":106,"acceptedAnswer":120},"What does the form say about missing required information?",{"text":121,"@type":109},"It warns that absence of required information may lead to delays in referral processing, or the referral being declined.","https://schema.org",{"og:url":78,"og:type":124,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":126,"canonical":78},"index,follow",{"doc_id":128,"site_id":56},280992,1789563440,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":88,"user_avatar":133,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":30,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":139,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":61,"update_tm":129,"read_time":9},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","*XX221J*  \nof 2  \nau  \n\n| Last name* |  | First name/s* |  |\n| --- | --- | --- | --- |\n\n\n| The Alfred T 03 9076 2025 F 03 9076 6938 [E](E op.referrals@alfred.org.au)[ ](E op.referrals@alfred.org.au)[op.referrals@alfred.org.au](E op.referrals@alfred.org.au)\u003Cbr>Sandringham T 03 9076 1288 F 03 9076 1252 [E](E op.referrals@alfred.org.au)[ ](E op.referrals@alfred.org.au)[op.referrals@alfred.org.au](E op.referrals@alfred.org.au)\u003Cbr>Caulfield T 03 9076 6800 F 03 9076 6435 [E](E consultingsuites@alfred.org.au)[ ](E consultingsuites@alfred.org.au)[consultingsuites@alfred.org.au](E consultingsuites@alfred.org.au)\u003Cbr>Your patient will be contacted with appointment details |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Patient details  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Date of birth* |  |  |  | Sex at birth |  |  | 􀂅 Female 􀂅 Male 􀂅 Other |  |  |  |  |  |  |  |  |\n| Gender\u003Cbr>identity | 􀂅 Female 􀂅 Male 􀂅 Non binary 􀂅 Not stated 􀂅 Prefer not to answer 􀂅 Different term |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Address* |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Telephone* |  |  |  |  |  |  |  | Email |  |  |  |  |  |  |  |\n| Preferred contact method |  |  | 􀂅 Telephone 􀂅 SMS 􀂅 Email 􀂅 Letter |  |  |  |  |  |  |  |  |  |  |  |  |\n| Medicare No |  |  | Reference |  |  |  |  | Expiry |  |  | NDIS number |  |  |  |  |\n| Private health insurance number |  |  |  |  |  |  |  |  |  | 􀂅 TAC 􀂅 WorkCover 􀂅 Other |  |  |  |  |  |\n| Pension card number |  |  |  |  |  |  |  |  |  | DVA number |  |  |  |  |  |\n| Interpreter | 􀂅 Yes 􀂅 No |  | Language |  |  |  |  |  |  |  |  |  |  |  |  |\n| Aboriginal status |  | 􀂅 Not Aboriginal or Torres Strait Islander\u003Cbr>􀂅 Torres Strait Islander not Aboriginal\u003Cbr>􀂅 Aboriginal not Torres Strait Islander |  |  |  |  |  |  |  | 􀂅 Aboriginal and Torres Strait Islander\u003Cbr>􀂅 Question unable to be asked\u003Cbr>􀂅 Patient declined to answer |  |  |  |  |  |\n| Cultural / support needs |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Contact person name |  |  |  |  | Relationship |  |  |  |  |  |  | Telephone |  |  |  |\n\n*mandatory fields  \n\n| Specialist clinic requested |  | Name of specialist |  |  |\n| --- | --- | --- | --- | --- |\n| Has this referral been discussed with the Unit Registrar? 􀂅 Yes Registrar name |  |  |  |  |\n\n\n| Reason for referral / health issues to be addressed (essential information for referral to be accepted) |\n| --- |\n| Presenting problem / working diagnosis / current management and response to treatment |\n\nFeb 2025 Page 2 of 2  \n[Source: www.AlfredHealth.org.au](Source: www.AlfredHealth.org.au)  \n\n| Last name* |  | First name/s* |  |\n| --- | --- | --- | --- |\n\n\n| Investigations and results list 􀂅 nil or 􀂅 relevant histopathology /investigations attached |  |  |\n| --- | --- | --- |\n| Medications list below 􀂅 nil or 􀂅 medication list attached |  |  |\n| Drug name | Strength | Dose / frequency |\n|  |  |  |\n\n\n| Allergies |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Alerts / risks |  |  |  |  |  |  |  |  |\n| Medical history 􀂅 Mental health 􀂅 Surgical 􀂅 Cancer 􀂅 Community supports |  |  |  |  |  |  |  |  |\n| Additional considerations functional impairments; impact on work, study or school; impact on caring responsibilities; social impact; comorbidities; quality of life |  |  |  |  |  |  |  |  |\n| Patient Portal\u003Cbr>The Patient Portal enables patients to easily access their Alfred Health appointment and health information online. Patients are encouraged to register, once they have received a Medical Record Number.\u003Cbr>[https://www.alfredhealth.org.au/patients-families-friends/patient-portal](https://www.alfredhealth.org.au/patients-families-friends/patient-portal) |  |  |  |  |  |  |  |  |\n| Referring medical practitioner details |  |  | Date of referral |  |  |  | Provider No |  |\n| Referral period |  |  | 􀂅 3 months 􀂅 12 months 􀂅 Indefinite |  |  |  |  | ","cbCaipT0zHQe7VA7","https://ap.wps.com/l/cbCaipT0zHQe7VA7","pdf",319518,"English","# Patient details\n## Specialist clinic request and referral discussion\n## Referral reason and essential clinical information\n## Investigations, medications, allergies, and medical history\n## Referring practitioner details and referral settings","[{\"question\":\"What information is required from the patient for this referral?\",\"answer\":\"The form collects mandatory patient demographics, contact details, sex/gender identity, address and telephone, Medicare and other identifiers, interpreter needs, and Aboriginal status. It also requests contact person information and preferred contact method.\"},{\"question\":\"What clinical details must be included for the referral to be accepted?\",\"answer\":\"The referral must specify the requested specialist clinic and include the reason for referral, presenting problem or working diagnosis, and current management with response to treatment. It also requests key attachments such as relevant investigations or histopathology and a medication list if applicable.\"},{\"question\":\"How does the form handle investigations, medications, allergies, and medical history?\",\"answer\":\"Sections allow listing investigations and results (or indicating none/attachments), documenting medications (or indicating none/attachments), recording allergies, and noting alerts or risks. Medical history options and additional considerations are also captured.\"},{\"question\":\"What does the form say about missing required information?\",\"answer\":\"It warns that absence of required information may lead to delays in referral processing, or the referral being declined.\"}]","Referral to Specialist Outpatient Clinics - Patient Referral Form | PDF"]