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 to: Dr Stephen Yelland 352395B	FROM <<Doctor:Name>>
Practice: <<Practice:Name>>
Phone: <<Practice:Phone>>
Fax: <<Practice:Fax>>
Email:<<Practice:E-mail>>
Provider Number: <<Doctor:Prescriber Number>>

<<Miscellaneous:Date>>

Dear Dr Yelland

SECTION 1 Patient details

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB (long)>>

Gender: <<Patient Demographics:Gender>>
Address:<<Patient Demographics: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)
	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:Ethnicity>> 
Interpreter required: <<Patient Demographics:Requires Interpreter>>
If yes, specify language: <<Patient Demographics:Language Preferred>>	

SECTION 2 Reason for referral and additional clinical information

What is the reason for this referral: <<What is the main reason for this referral?>>
Please provide provisional diagnosis (if available): <<Please provide 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: <<Clinical Details:History List>>
Alcohol: <<Clinical Details:Alcohol>>
Smoking: <<Clinical Details:Smoking>>
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>
Current prescribed medications: <<Clinical Details:Medication List>>

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:
<<Summary:Investigation Results (Selected)>> 

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.