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 (one clinician only):
OR FIRST AVAILABLE   q  	

Patient Details and Communications	
PATIENT SURNAME: <<Patient Demographics:Surname>>	FIRST NAME: <<Patient Demographics:First Name>>	
TITLE: <<Patient Demographics:Title>>	DOB: <<Patient Demographics:DOB>>	GENDER: <<Patient Demographics:Gender>>	
ADDRESS: <<Patient Demographics:Address>>	HOME CONTACT: <<Patient Demographics:Phone (Home)>>	
<<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	MOBILE CONTACT: <<Patient Demographics:Phone (Mobile)>>	
EMAIL:<<Patient Demographics:E-mail>>	INTERPRETER REQUIRED: <<INTERPRETER REQUIRED:>>	
COMMUNICATION PREFERENCE: <<COMMUNICATION PREFERENCE:>>	

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

	LANGUAGE / DIALECT: <<LANGUAGE / DIALECT:>>
	
q  Non-Medicare     q  WorkCover     q  DVA       q  Medicare	MEDICARE NO. <<Patient Demographics:Medicare Number>>	
CARER/NEXT OF KIN DETAILS: 
<<CARER or NEXT OF KIN (Name)>>      <<CARER or NEXT OF KIN (Phone)>>      <<CARER or NEXT OF KIN (email)>>

(Name)                                                                                    (Telephone)                                          (Email details)	
SPECIALS NEEDS / REASONABLE ADJUSTMENTS FOR DISABILITY: (specify)

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

Health Summary Attached   q         Relevant Results Attached   q	

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

Outpatient Department Clinic and Clinician Details 	

Geriatric Clinic
Dr Sarah Baldwin   
Dr Yun Xu 
Dr Chuang 
Dr Tony Youssef
Dr Litsa Morfis     
Dr Madeleine Wilkinson
Dr Grant Pickard  	
Neurology Clinic
Dr Louise Allport            
Prof Mark Hersch        
Dr Jane Prosser         
Dr Elizabeth Shiner           
Dr Mahtab Ghadiri    
Dr Justine Wang
Dr Monica Badve
Dr Walid Matar	
Haematology Clinic
Dr Beng Chong
Dr Sylvia Zheng
Dr Qin Liu
Dr Amanda Hugman	
Diabetic / Endocrine Clinic
Dr Terry Diamond 
Dr Michael Reyes   
Dr Peter Rohl
Dr Anthony 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	

Dermatology Clinic
Prof Dedee Murrell 
Dr Ben Daniel
	
Infectious Disease Clinic
Dr Chris Weatherall 
Dr Pamela 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: If no clinician preferred and you would request the next available clinician, please specify this in the clinician name section.