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

To:  <AdrName>
	
Name:	<PtFullName>	
Address:	<PtStreet> <PtCity> <PtPostcode> <PtState>	
		
DOB:	<PtDoB>	
Gender:	<PtSex>	
Telephone Contact:	Home: <PtPhoneH>	Mobile: <PtPhoneMob>	Work: <PtPhoneWk>	
Alternative Contact:	Name: <NOKName>	Phone:<NOKContact>		
 DVA/Medicare:	<PtDVANo> 	 <PtMCNo>		
Interpreter Required:	<Interpreter Required>		If Yes, language:	

Presenting Problem:                     	<TodaysVisit><VisitReason>

Thank you for seeing <PtFullName>, age <PtAge>, for an opinion and management.

Past History: <PMHAll>

Current Medications: <CurrentRx>

Allergies: <Reactions>

Urgent:  <Urgent>

Yours sincerely,

Signature:

Duration of referral: <Referral valid>	GP Name: <DrName>
Practice Name: <Practice>
Address: <UsrAddress>
Phone: <UsrPhone>
Fax: <UsrFax>
Provider No: <DrProviderNo>
Date: <TodaysDate>	

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