Outpatient Department: St George Hospital
Ground Fl, Prince William Wing
Telephone: 9113 2513 Fax: 9113 2297 Email: SESLHD-STG-OPD@health.nsw.gov.au	

                        Clinician Receiving Referral (clinic details available on page 2)	
CLINIC NAME: 	
 CLINICIAN NAME (if preferred):
 OR FIRST AVAILABLE   q  	

Patient Details & Communications	
PATIENT SURNAME: <<Patient Demographics:Surname>>	FIRST NAME: <<Patient Demographics:First Name>>    <<Patient Demographics:Middle Name>>	
TITLE: <<Patient Demographics:Title>>	DOB: <<Patient Demographics:DOB>>	GENDER: <<Patient Demographics:Gender>>	
ADDRESS:  <<Patient Demographics:Address>>	HOME CONTACT: <<Patient Demographics:Phone (Home)>>	

MOBILE CONTACT: <<Patient Demographics:Phone (Mobile)>>	

EMAIL: <<Patient Demographics:E-mail>>	INTERPRETER REQUIRED: <<Interpreter required>>	
COMMUNICATION PREFERENCE:<<Communication Preferences>>	

IDENTIFIES AS ABORIGINAL / TORRES STRAIT ISLANDER ORIGIN: <ATSI>	

	LANGUAGE / DIALECT: <<Patient Demographics:Language Spoken>>	
  <<non-Medicare>> Non-Medicare            <<Workcover>>   WorkCover	 		MEDICARE NO. <<Patient Demographics:Medicare Number>>	
CARER/NEXT OF KIN DETAILS:
<<Patient Demographics:Next of Kin>>     <<Patient Demographics:Next of Kin Phone>>      <<NOK Email>>	
(Name)	(Telephone)	(Email details)	
SPECIALS NEEDS / REASONABLE ADJUSTMENTS FOR DISABILITY: (specify)	

Patient Healthcare Details	
NAME OF GP: (If not referrer) 
<<Doctor:Name>>	GP PROVIDER NO: (If not referrer)
<<Doctor:Provider Number>>	
CLINICAL INFORMATION / REASON FOR REFERRAL: Please attach relevant investigations and clinical history to prevent any triage delays. Please also include any patient risk factors.

Today's Visit Notes: <<Summary:Progress Notes (Selected)>>
Current Medications: <<Clinical Details:Medication List>>
Past Medical History: <<Clinical Details:History List>>
Investigations Results: <<Summary:Investigation Results (Selected)>>	

Referring Clinician Details	
REQUESTING DR: <<Doctor:Name>>	PROVIDER NO. <<Doctor:Provider Number>>	DATE: <<Miscellaneous:Date>>	
ADDRESS: <<Doctor:Address>>	
TELEPHONE: <<Doctor:Phone>>	FAX: <<Doctor:Fax>>	SIGNATURE:  	

Outpatient Department Clinic & Clinician Details	

Geriatric Clinic Dr Sarah Baldwin Dr Yun Xu
Dr Chuang
Dr Tony Youssef Dr Litsa Morfis
Dr Madeleine Wilkinson Dr Grant Pickard	
NeurologyClinic Dr Louise Allport Prof Mark Hersch Dr Jane Prosser
Dr ElizabethShiner Dr Mahtab Ghadiri Dr Justine Wang Dr Monica Badve
Dr Walid Matar	
Haematology Clinic
Dr Beng Chong DrSylvia Zheng Dr Qin Liu
Dr Amanda Hugman	
Diabetic / Endocrine Clinic
DrTerry Diamond Dr Michael Reyes Dr Peter Rohl
DrAnthony O’Sullivan Prof Peter Smerdely	

Drug & Alcohol Clinic
Dr Peter Gottlieb	
Rheumatology Clinic
Dr Bill Giannakopoulos	
Wound Clinic
Wound CNC	
Immunology
Prof Steven Krilis	

Movement Disorder Clinic
Dr Stephen Duma	
Colorectal Clinic
Prof David Lubowski	
Gastroenterology
Dr Gokulan Pavendranathan	
Swallow
Dr Peter Wu	

DermatologyClinic Prof Dedee Murrell Dr Ben Daniel	
Infectious Disease Clinic
Dr Chris Weatherall DrPamela Konecny Dr Richard Sullivan	
Vascular Clinic Dr Eric Farmer Dr Jim Iliopoulos
Dr Lubomyr Lemech	
IBD
Prof Michael Grimm
Dr Gokulan Pavendranathan Dr. William Bye	
NOTE: Please request the next available clinician if no clinician is preferred. Kindly specify this in the clinician’s name section.