Medical Ambulatory Care Services (MACS)
General enquiries: Ph:0466 439 479 Fax: 08 8488 6037	

To:<<Addressee:Name>>
	
Name:	<<Patient Demographics:Full Name>>	
Address:	<<Patient Demographics:Address>> <<Patient Demographics:City>> <<Patient Demographics:State>> <<Patient Demographics:Postcode>>	
		
DOB:	<<Patient Demographics:DOB>>	
Gender:	<<Patient Demographics:Gender>>	
Telephone Contact:	Home: <<Patient Demographics:Phone (Home)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	Work: <<Patient Demographics:Phone (Work)>>	
Alternative Contact:	Name: <<Alternative patient contact name>>	Phone: <<Alternative patient contact phone>>		
 DVA/Medicare:	 <<Patient Demographics:DVA Number>>	 <<Patient Demographics:Medicare Number>>		
Interpreter Required:	<<Interpreter Required>>		If Yes, language:	

Presenting Problem:              	<<Operation:Presenting Problems>>

Thank you for seeing <<Patient Demographics:Full Name>>, age <<Patient Demographics:Age>>, for an opinion and management.

Past History:  

Current Medications: <<Clinical Details:Medication List>>

Allergies: <<Clinical Details:Allergies>>

Urgent: <<Urgent >>

Yours sincerely,

Signature:

Duration of referral: <<Duration of referral >>	GP Name: <<Doctor:Name>>
Practice Name: <<Practice:Name>>
Address: <<Practice:Address>>
Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
Provider No: <<Doctor:Provider Number>>
Date: <<Miscellaneous:Date>>	

Summary/copies of investigations or other documents appended, as appropriate: