REQUEST FOR CONSULTATION:
COMPLEX WOUND CLINIC
BUNDALL MEDICAL CENTRE
Referral for assessment of patient for wound care

SEND TO Dr Stephen Yelland (General Practitioner)
Complex Wound Clinic
Bundall Medical Centre
21 Ashmore Rd
Bundall

Secure Transmission Service via Medical Objects: 
Dr Stephen Yelland 352395B	FROM: <DrName>
Practice: <Practice>
Phone: <UsrPhone>
Fax: <UsrFax>
Email: <PracEmail>
Provider Number: <DrProviderNo>

<TodaysDate>

Dear Dr Yelland

SECTION 1 Patient details

RE: <PtFullName>
DOB: <PtDoB>

Gender: <PtSex>
Address:<PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Medicare Number*: <PtMCNo> (*Medicare ineligible patients will incur a consultation fee)
	Next of Kin/Alternative Contact: <NOKName>
Next of Kin/ Alternative Contact Ph: <NOKContact>
Does the patient identify as Aboriginal and/or Torres Strait Islander: <Does pt identify as Aboriginal/Torres Strait Islander>
Interpreter required: <Interpreter required>
If yes, specify language: <If yes, specify language>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <Specify main reason for referral>
Please provide provisional diagnosis (if available): <Provisional diagnosis if available>
Please provide history of wound (if known): <History of wound>
Please provide date of onset if known: <Date of onset of wound if known>
Please include details of treatment regime so far: <Please provide details of treatment regime so far>            
Has any compression therapy been used: <Has any compression therapy been used?>  
If compression therapy has been used, what type: <If compression therapy has been used, what type?>    
Please provide relevant information: 
Clinical examination findings: <Please provide relevant clinical examination finding>  
List any other members of management team eg Specialists, Podiatrists, Domiciliary nursing: <Provide names of any other care providers> 
Please provide details of any in patient or outpatient care to date: <Please provide any inpatient or outpatient care>

SECTION 3 Mandatory clinical information

Please include patient health summary and/or a copy of the GPMP and TCA containing this information. (This will allow the Wound Clinic to contribute to the patient's Care Plan) 
Information to include:
Current and Past Medical History: <PMHAll>
Alcohol: <AlcHx>
Smoking: <SmkStatus> <SmkHx>
Allergies: <Reactions>
Current prescribed medications: <CurrentRx>

SECTION 4 Investigations

Please indicate whether the following investigations have been undertaken and attach the results. In addition, please also attach any investigation results you consider to be relevant.

Please include the following results if available: 
FBC, E/LFTs, ABI, Imaging, Arterial/Venous duplex scans, Biopsy, Microbiology:
<Ix>

SECTION 5 Social factors and impact on the patient

Consider the impact on employment/education; activities of daily life; ability to care for others; personal safety/frailty; other factors. Please paste or type relevant information.