To ensure a timely appointment, complete all sections of this form. Incomplete forms will be returned for completion
					Medical Object ID: HM4101000R8
					Healthlink EDI: materref
Patient Details:
Re: <<Patient Demographics:Full Name>>
Surname: <<Patient Demographics:Surname>>
Given Names: <<Patient Demographics:First Name>>
Parent/Guardian's full name: <<Parent/Guardians full name>> Date of Birth: <<Patient Demographics:DOB>>	Sex: <<Patient Demographics:Sex>>
Patients Address: <<Patient Demographics:Full Address>>
Home Phone No.: <<Patient Demographics:Phone (Home)>>
Mobile Phone No.: <<Patient Demographics:Phone (Mobile)>>
Interpreter required?: <<Interpreter Required?>>	Language: <<Language>>
Aboriginal/Torres Strait Islander origin: <<Aboriginal / Torres Strait Islander Origin>>
Medicare Eligible?: <<Medicare Eligible?>>	Medicare No.: <<Patient Demographics:Medicare Number>>
Private Health Insurance: <<Private Health Insurance?>>
NDIS Participant: <<NDIS Participant? >>	If YES NDIS No.: <<If YES, NDIS No. >>
Compensable Status: <<Compensable Status>>Other Compensable: <<Other Compensable Status (please specifiy)>>

Reason for Referral: Please include all essential condition-specific information outlined in standard referral guidelines, located at www.materonline.org.au	
Provisional Diagnosis / Presenting Condition / What question/s are you asking of your specialist colleagues:
<<Provisional Diagnosis / Presenting Condition>>
	
Relevant Clinical History / Examination: 
<<Summary:Progress Notes (Selected)>>

<<Clinical Details:History List>>
	
My patient's condition corresponds with the following urgency category and associated clinically recommended waiting time as per Referral Criteria @ Mater Online: 
<<Referral guidelines indicate the following urgency>>	
Allergies: 
<<Clinical Details:Allergies>>
	
Medications: 
<<Clinical Details:Medication List>>
	
Relevant Investigations: 
<<Summary:Investigation Results (Selected)>>

Referral Details - Please select a Head of Specialty/Clinic
(To reduce waiting times, this referral may be shared with other Specialists)	
Referred to: <<Referred to Clinician>> <<Other Doctor>>
Date of Referral: <<Miscellaneous:Date>>
Continuation Referral: <<Continuation Referral>>	
Updated Referral: <<Updated Referral>>
Duration of Referral: <<Length of Referral>>
This patient may be eligible for a telehealth consult: <<This patient may be eligible for a telehealth consult?>>
Is the referring practitioner to be involved in the telehealth consultation: <<Is the referring doctor to be involved in the consult?>>
Referring Clinician: <<Doctor:Name>> Provider No.: <<Doctor:Provider Number>>
Address:<<Doctor:Full Address>>
Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	
Email: <<Doctor:E-mail>>
Signature: