GP REFERRAL FORM

Please complete this form or provide a referral letter.
GP referrals are valid for 12 months.
Fax: (02) 9515 1220 or email: SLHD-RPAClinic@health.nsw.gov.au.

Referral to:
Professor David Templeton, RPA Sexual Health, 16 Marsden Street, Camperdown, NSW 2050 

PATIENT DETAILS:	REFERRING DOCTOR:	
Name: <PtName>	Name: <DrName>	
Date of Birth: <PtDoB>	Provider Number: <DrProviderNo>	
Address:
<PtStreet>
<PtCity> <PtState> <PtPostcode>

Medicare no: <PtMCNo>	Address: 
<DrStreet>
<DrCity> <DrState> <DrPostcode>

Telephone: <DrPhone>	

Telephone (h): <PtPhoneH>
(m) <PtPhoneMob>	Fax: <DrFax>	
Results attached :	Reason for referral:	
  o STI testing
  o Hepatitis serology
  o EUC, LFT
  o Other - 	  o Opinion
  o Continuing management
  o Treatment
  o Other - 	
COMMENTS	

Signature:	Date: <TodaysDate>