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:
Dr Rachel Burdon, RPA Sexual Health, 16 Marsden Street, Camperdown, NSW 2050 

PATIENT DETAILS:	REFERRING DOCTOR:	
Name: <<Patient Demographics:Full Name>>	Name: <<Doctor:Name>>	
Date of Birth: <<Patient Demographics:DOB>>	Provider Number: <<Doctor:Provider Number>>	
Address:
<<Patient Demographics:Address>>
<<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>

Medicare no: <<Patient Demographics:Medicare Number>>	Address: 
<<Doctor:Address>>
<<Doctor:City>> <<Doctor:State>> <<Doctor:Postcode>>

Telephone: <<Doctor:Phone>>	

Telephone (h): <<Patient Demographics:Phone (Home)>>
(m) <<Patient Demographics:Phone (Mobile)>>	Fax: <<Doctor:Fax>>	
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: <<Miscellaneous:Date (short)>>