GP to GP colleague referrals form
•	All fields are mandatory.
•	If urgent attention is required, please follow the relevant clinical guidance to best manage patient symptoms and refer to appropriate specialist/ED as required.
Info for referring and accepting GP: 
•	Referring GP to send completed form and all attachments to accepting GP via HealthLink, fax or secure messaging platform.
•	Referring GP is responsible for patients’ ongoing care.
•	Accepting GP is responsible for reviewing referral form and contacting patient to make an appointment only if they have capacity to do so. 
•	Accepting GP will assess patient then provide prescription for any medication/consumables required to complete treatment/procedure.
•	Accepting GP is expected to advise the referring GP of outcome of assessment/procedure and any further actions required.

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Dear Dr <<Addressee:Name>>
Thank you for seeing my patient for assessment and procedure as indicated below:. 
Referring GP details	
Name: <<Doctor:Name>>
Practice name: <<Practice Name>>
Practice address: <<Practice/Location:Address>>
Phone number: <<Practice/Location:Phone>>
Email: <<Doctor:E-mail>>	Practice stamp

Provider number
<<Doctor:Provider Number>>	

Patient Details:	
Patient Name:	<<Patient Demographics:Full Name>>	Patient DOB:	<<Patient Demographics:DOB>>	
Sex:	<<Patient Demographics:Gender>>	Patient Phone Number:	<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:Phone (Mobile)>>	
Patient Email:	<<Patient Demographics:E-mail>>	Language Spoken:
If not English, is interpreter required?	<<Patient Demographics:Language Spoken>>
<<Is interpreter required?>>	
Is Patient Aboriginal or Torres Strait Islander?	<<Is Patient Aboriginal or Torres Strait Islander?>>	Is Patient currently pregnant?	<<Is Patient currently pregnant?>>	
Does Patient have any known allergies?	<<Clinical Details:Allergies/Adverse Reactions>>	
		
Emergency Contact:	<<Patient Demographics:Emergency Contact>>	Emergency Contact Phone:	<<Patient Demographics:Emergency Contact Phone>>	

Service Required:	
<<Service Required>>

Additional Clinical Information:	
<<Additional Clinical Information>>	

Please provide any additional supporting documentation and relevant investigations with this referral form.
For information on local practitioners offering specialist GP services, please refer to General Practice (GP) Colleague Referrals - Community HealthPathways South Western Sydney.

This referral form was created for GPs by South Western Sydney HealthPathways.