Haematology: St George Hospital Telephone: 9113 3851 or 9113 2692 Fax: 9113 3958 Email: SESLHD-st-george-haematology- secretaries@health.nsw.gov.au	

Haematologist Receiving Referral (clinic details available on page 2)	
HAEMATOLOGIST NAME (one clinician only):  <Haematologist>	

Patient Details and Communications	
PATIENT SURNAME:  <PtSurname>	FIRST NAME:  <PtFirstName>	
TITLE:  <PtTitle>	DOB:  <PtDoB>	GENDER:  <GenderIdentity>	
ADDRESS:  <PtAddress>	HOME CONTACT:  <PtPhoneH>	
	MOBILE CONTACT:  <PtPhoneMob>	
EMAIL:  <PtEmail>	INTERPRETER REQUIRED:  <Interpreter_required>	
COMMUNICATION PREFERENCE:  <Communication _preference>	LANGUAGE / DIALECT:  <Preferred_language>	
IDENTIFIES AS ABORIGINAL / TORRES STRAIT ISLANDER ORIGIN: Yes / No		
Non-Medicare <Non-Medicare>	Workcover  <Workcover>	DVA  <DVA>	Medicare  <Medicare>	MEDICARE NO.  <PtMCNo>	
IF THE PATIENT HAS A CARER:
Name:  <Carer_name>                         Phone No:   <Carer_Phone>                   Email:  <Carer_Email>	
SPECIALS NEEDS / REASONABLE ADJUSTMENTS FOR DISABILITY: (specify)	

Patient Healthcare Details	
NAME OF GP: (If not referrer)
<DrName>	GP PROVIDER NO: (If not referrer)
<DrProviderNo>	
CLINICAL INFORMATION / REASON FOR REFERRAL: Please attach relevant investigations to prevent triage delays.	

Referring Clinician Details	
REQUESTING DR:
<DrName>	PROVIDER NO.
<DrProviderNo>	DATE:
<TodaysDate>	
ADDRESS:  <DrAddress>	
TELEPHONE:  <DrPhone>	FAX:  <DrFax>	SIGNATURE:  	

Clinician Details	
Head of Department	Dr Shir-Jing Ho	MBBS FRACP FRCPA M Clin Tr Res	
Senior Staff Specialist	Dr Beng Chong	MBBS PhD FRACP FRCPA FRCP	
Senior Staff Specialist	Dr Sundra Ramanathan	MBBS FRACP FRCPA	
Staff Specialist	Dr Amanda Hugman	MBBS FRACP FRCPA M Phil	
Staff Specialist	Dr Fernando Roncolato	BMed FRACP FRCPA	
Staff Specialist	Dr Xavier Badoux	MBBS FRACP FRCPA	
Staff Specialist	Dr Charles Shuttleworth	MBBS FRACP FRCPA	
Staff Specialist	Dr Silvia Zheng	MBBS FRACP FRCPA	
Staff Specialist	Dr Qin Liu	MBBS FRACP FRCPA	

Additional Investigations Prior to Haematology Appointment	
To help streamline our clinics and allow for us to see your patients more expeditiously we have recommended further investigations to be organized by the referring practitioner at the time of referral. Repeat and additional blood collections ideally should be performed at St George Hospital BEFORE the initial appointment.	
Anaemia: Iron studies, B12 and folate. Assess for bleeding.	
Microcytic anaemia: Iron studies. Haemoglobin EPG if iron studies are unremarkable, there is a family history of thalassaemia or patient is pregnant.	
Persistent/progressive lymphocytosis: Peripheral blood flow cytometry. Imaging if lymphadenopathy on physical examination.	
Persistent/progressive thrombocytosis: Iron studies, JAK2, CALR, MPL, BCR-ABL genetic testing. Assess for infective/inflammatory cause.	
Elevated haemoglobin: JAK2 genetic testing, EPO level. Assess for chronic hypoxia.	
Persistently/progressively raised ferritin: HFE gene testing, liver function testing.	

Please note iron infusion referrals can be sent to the Ambulatory Care Unit at St George Hospital directly and may not require a referral to see a Haematologist.