Medical Ambulatory Care Services (MACS)
General enquiries: Ph: 0466 439 479 Fax: 08 8164 9168	

To:  Addressee.Name
	
Name:	Patient Demographics.Full Name	
Address:	Patient Demographics.Full Address	
		
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: Patient Demographics.NOK Name	Phone: Patient Demographics.NOK Home Phone	Mobile:Patient Demographics.NOK Mobile Phone	
 DVA/Medicare:	 Patient Demographics.DVA Number	 Patient Demographics.Medicare Number		
Interpreter Required:	Interpreter		If Yes, language:	

Presenting Problem:            
 Clinical Details.Problem List (Current)

Thank you for seeing Patient Demographics.First Name, age Patient Demographics.Age, for an opinion and management.

Past History: Clinical Details.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: Treating Doctor.Name
Practice Name: 
Address: Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Provider No: Treating Doctor.Provider Number
Date: Miscellaneous.Date	

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