If any of the following are present or suspected, refer the patient to the emergency department (via ambulance if necessary) or seek emergent medical advice if in a remote region.

• Traumatic tooth injuries with associated injuries including:
  
  • Large
    lacerations
    
  • Associated
    jaw fracture
    
• Refer immediately in the presence of severe infection including:
  
  • Limited
    eye opening
    
  • Facial
    swelling
  • Increasing Pain
  • Tinnitus
  • Dysphagia
• Cervicofacial infections with deep space and/or acute or potential airway compromise
• All paediatric orbital fractures
• Adult orbital fractures with vision compromise
• Midface fractures with concern for retrobulbar haemorrhage
• Facial trauma with uncontrolled haemorrhage
• New findings of symptomatic brain metastasis or leptomeningeal disease diagnosed in the community

Needs prompt maxillofacial assessment (rapid phone call and same day assessment):

• Compound and full thickness facial lacerations
• Cervicofacial infections
• Facial nerve trauma
• Non-orbital paediatric trauma
• Mandibular fractures

Needs sub-acute maxillary assessment (rapid phone call and maxillofacial registrar triaging):

• Concern for maxillofacial head and neck cancer
  • Oral cavity cancer
  • Jaw Cancer
  • Paranasal sinus cancer
  • Salivary gland cancer
  • Advanced facial skin cancer
  • Cervical lymphadenopathy
• Adult orbital fractures without vision compromise
• Frontal bone and frontal sinus fractures
• Mid-face fractures
  • Naso-orbito-ethmoid
  • Nasal
  • Maxillary
  • Maxillary sinus
  • LeFort I, II, III
  • Zygomatic; zygomaticomaxillary complex (ZMC) and zygomatic arch
  • Dental trauma

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.)