• Potentially life-threatening symptoms suggestive of:
  • acute upper GI tract bleeding
  • acute severe lower GI tract bleeding
  • oesophageal foreign bodies/food bolus
  • Acute Severe colitis*
  • bowel obstruction
  • abdominal sepsis
• Severe vomiting and/or diarrhoea with dehydration
• Acute/fulminant liver failure (to be referred to a centre with dedicated Hepatology services)
• Biliary sepsis (to be referred to a centre with ERCP service)
  

*Acute severe colitis is defined by the Truelove and Witts criteria – all patients with ≥6 bloody bowel motions per 24 hours plus at least one of the following:

• Temperature at presentation of >37.8°C
• Pulse rate at presentation of >90bpm
• Haemoglobin at presentation of <105gm/l, CRP >30mg/dl (or ESR >30mm/hr)

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.)