Diabetes

• Diabetic ketoacidosis
• Diabetes and severe vomiting
• Acute severe hyperglycemia
• Acute severe hypoglycaemia
• Hyperosmolar hyperglycaemic state (HHS)
• Newly diagnosed type 1 diabetes
  

High Risk Foot

• Foot ulcer with infection and systemically unwell or febrile
• Invasive infection or rapidly spreading cellulitis (defined by peripheral redness around the wound > 2cm)
• Acute Ischaemia
• Wet Gangrene
• Acute or suspected Charcot foot

Thyroid disorders

• Hyperthyroidism complicated by cardiac, respiratory compromise or other indications of severe illness (fever, vomiting, labile blood pressure, altered mental state)
• Neutropenic sepsis in patient taking carbimazole or propylthiouracil
• Hyperthyroidism with hypokalaemia or paralysis
• Suspected myxoedema coma (altered consciousness, hypothermia, fluid overload, bradycardia, hyponatraemia)
• Stridor associated with a thyroid mass
• Possible tracheal or superior vena cava obstruction from retrosternal thyroid enlargement

Adrenal disease

• Addisonian crisis
• Suspected or confirmed acute adrenal insufficiency
• Phaeochromocytoma in crisis with uncontrolled hypertension
• Malignant hypertension

Pituitary disorders

• All patients with visual field loss (usually temporal and classically bitemporal superior quadrantopia / hemianopia)
• Pituitary tumour with severe headache
• Pituitary tumour with evidence of symptomatic cortisol insufficiency
• Hyperprolactinaemia with visual impairment or other neurological signs

Calcium, electrolyte and metabolic bone disorders

• Acutely symptomatic hypocalcaemia (e.g. tetany) with serum calcium <2.0mmol/L
• Severe symptomatic hypercalcaemia (usually serum calcium > 3.0 mmol/l)
• Hypernatraemia or hyponatraemia with acute confusion/delirium
• Suspected or confirmed diabetes insipidus with hypernatraemia

Reason for request

• To establish a diagnosis
• For treatment or intervention
• For advice and management
• For specialist to take over management
• Reassurance for GP/second opinion
• For a specified test/investigation the GP can't order, or the patient can't afford or access
• Reassurance for the patient/family
• For other reason (e.g. rapidly accelerating disease progression)
• Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

• Presenting symptoms (evolution and duration)
• Physical findings
• Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
• All conservative options that have been pursued unsuccessfully prior to referral
• Body mass index (BMI)
• Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
• Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
• Current medications and dosages
• Drug allergies
• Alcohol, tobacco and other drugs use

Patient's Demographic Details

• Full name (including aliases)
• Date and country of birth
• Residential and postal address including whether patient resides at an aged care facility
• Telephone contact number/s – home, mobile and alternative
• Medicare number (where eligible)
• Name of the parent or caregiver (if appropriate)
• Name of delegate and contact details (Department of Corrective Services)
• Preferred language and interpreter requirements
• Identifies as Aboriginal and/or Torres Strait Islander
• Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

• Full name
• Full address
• Contact details – telephone, fax, email
• Provider number
• Date of referral
• Signature
• Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

• Willingness to have surgery (where surgery is a likely intervention)
• Choice to be treated as a public or private patient
• Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)