Patient information
General Practitioner Details (please print clearly)
Royal Adelaide Hospital UR Number:
Date:
«datel»
Given Names
«givennames»
Name:
«docname»
Surname
«surname»
Clinic:
«sitename»
Address:
«siteaddr1» «siteaddr2»
Previous Name
Address
«address1» «address2»
«siteaddr3»
«address3»
Phone
Date of Birth
«phoneh» (Home)
Phone:
«sitephone»
«phonew» (Work)
Fax:
«sitefax»
«dob»
Signature:
Interpreter required Language:
Referral to:
Specialist Outpatient Clinic
«selspeciality»
Emergency Department (ED)
I have contacted a RAH staff member
Clinic (details overleaf- including fax number)
Doctor
«selformalname»
Appointment date if
known:
Contact Name:
Contact Date & Time
Urgency of Appt
within 2 weeks  2 - 4 weeks
4 - 6 weeks 6 - 8 weeks
3 months
NON URGENT
Non-urgent to be brought in with patient
YES /
NO
All urgent ED referrals only fax to 8222 5959.
Is the patient currently receiving home support?
YES /
NO
Will patient need home support following discharge?
YES /
NO
Does this patient have any infectious diseases?
YES /
NO /
If YES, please state:
UNKNOWN
History & Examination (current problem)
«printclinicalhistory»
Relevant Past History (medical, surgical, social, family etc.)
Allergies
«printallergies»
Medications
«printcurrentmedication»
Provisional / Differential Diagnosis
Investigations (please attach copies of all relevant
specialist Reports, X-rays, etc)
Highlighted areas signify a referral letter is needed prior to an appointment being made. This may be faxed or posted to the appropriate location.
Postal details: Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 (please mark to the attention of the relevant clinic)
CLINIC
Allergy/Immunology
Audiology
Breast
Breast Endocrine & Surgical Oncology
Cardiology, Clinical
LOCATION
TELEPHONE
FAX NO.
Level 8 Outpatient Block
Level 6 McEwin Link
8222 5583
8222 4288
8222 4034
8222 5944
Women's Health Centre
Level 5 Emergency Block
8222 5587
8222 5185
8222 5645
8222 5989
Level 6 Outpatient Block
8222 5173
8222 2887
Cardiothoracic Surgery
Level 4 East Wing Link
8222 5296
8222 5962
Colorectal Surgery (Surg-E)
Level 7 Outpatient Block
8222 5589
8222 5883
Clinical Psychology (Oncology)
Level 7 East Wing
Women's Health Centre
8222 5010
8222 5587
8222 2013
8222 5645
Diabetes Centre
Level 8 Outpatient Block
Level 3 Theatre Block
8222 5583
8222 5111
8222 4034
82224265
Dietetic / Retinal
Level 5 Outpatient Block
8222 5313
8222 5221
Dietetics General/Weight Loss
Level 9 Outpatient Block
Level 8 East Wing
8222 5174
8222 5203
8222 2053
8222 5907
Level 8 Outpatient Block
Level 9 Outpatient Block
8222 5583
8222 5174
8222 4034
8222 2053
Eyes
Level 5 Emergency Block
Level 5 Outpatient Block
8222 5185
8222 5313
82225989
8222 5221
Gastroenterology
Level 7 Outpatient Block
8222 5589
8222 5883
Level 8 Outpatient Block
Level 7 Outpatient Block
8222 5583
8222 5589
8222 4034
8222 5883
Level 5 Emergency Block
8222 5185
8222 5989
Level 8 Outpatient Block
8161 7375 (WCH)
8161 6088 (WCH)
8222 5215
Gynaecology-Oncology/Urology
Level 8 Outpatient Block
Women's Health Centre
8222 5587
8222 5725
8222 5645
Haematology
Level 7 East Wing
8222 5010
8222 2013
Hepato Biliary & Pancreatic Surg (Surg C
Level 7 Outpatient Block
Level 2 Theatre Block
8222 5589
8222 5116
8222 5883
8232 4207
Colonoscopy
Dermatology
Dietetics Renal
Drug and Alcohol
Endocrinology and Metabolism
ENT
General Medicine – Medicine 1 2 3 4
General Medicine – Medicine 5
General Surgery
Genetics SA - Clinical Genetics Service IMVS
Geriatric & Rehabilitation
Hyperbaric Medicine
Hypertension
Level 6 Outpatient Block
8222 5173
8222 2887
Hysteroscopy
Women's Health Centre
8222 5587
8222 5645
Infectious Diseases
Limb Prosthetics
Liver Disease Clinic
Level 8 Outpatient Block
Level 3 Theatre Block
8222 2954
8222 5584
8222 4034
8222 2751
Level 7 Outpatient Block
8222 5589
8222 5883
Lung Function Laboratory
Level 7 Outpatient Block
Women's Health Centre
8222 5433
8222 5587
8222 5955
8222 5645
Menopause
Level 7 East Wing
Women's Health Centre
8222 4406
8222 5587
8222 2013
8222 5645
Metabolic and Lipids
Neuropsychology
Level 9 Outpatient Block
Level 9 Outpatient Block
8222 5174
8222 5174
8222 2053
8222 2433
Neurology
Level 5 Emergency Block
8222 2172
8222 2984
Neurophysiology (EEG/EMG)
Level 5 Emergency Block
8222 5299
8222 5886
Neuropsychology Clinical
Neurosurgery
Level 9 Outpatient Block
8222 5174
8222 2433
Level 5 Emergency Block
Nuclear Medicine & Bone Densitometry
Obesity
Level 5 Emergency Block
Level 9 Outpatient Block
8222 5235
8222 5407
8222 5886
8222 4370
Oesophago Gastric Surgery (Surg AB)
8222 5174
8222 5589
8222 2433
8222 5883
Oral & Maxillo Facial Surgery
Level 5 Emergency Block
Level 7 Theatre Block
8222 8225
8303 4402
Orthopaedic & Trauma
Orthotics
Level 9 Outpatient Block
Level 7 Outpatient Block
8222 5584
8222 5288
8222 2751
8222 5951
Osteoporosis
Pain Management Unit
Adelaide Dental Hospital
8222 5174
8222 5403
8222 2433
8222 5904
8222 4406
8222 5334
8222 2013
8222 4279
Level 5 Emergency Block
8222 5174
8222 5185
8222 2433
8222 5989
Mammogram
Medical Oncology
Palliative Care
Physiotherapy
Pituitary
Plastic & Reconstructive Surgery
- Australian Craniofacial Unit
Level 3 Theatre Block
Level 2 Outpatient Block
Level 9 Outpatient Block
Level 6 Emergency Block
Level 5 Emergency Block
8222 5185
8222 5989
- Burns
- Facial Fracture Clinic
Level 5 Emergency Block
Level 5 Emergency Block
8222 5185
8222 5185
8222 5989
8222 5989
- Hands
- Microsurgery
Podiatry
Level 5 Emergency Block
Level 5 Emergency Block
8222 5185
8222 5185
8222 5989
8222 5989
Pre-anaesthetic assessment
Level 6 Outpatient Block
Level 3 Theatre Block
8222 5912
8222 5186
8222 2053
8222 4223
Psychiatry
Level 9 Outpatient Block
8222 5174
8222 2433
Radiation Oncology
Level 3 East Wing
8222 4383/8222 4390
8222 2016
Rehabilitation, Neurological (Head Injury)
Renal Medicine
Level 8 Outpatient Block
8222 5915
8222 4034
Level 6 Emergency Block
8222 5203
8222 5907
Rheumatology
Sleep Disorders Service
Speech Pathology
Level 3 Theatre Block
Chest Clinic
8222 5910
8222 5286
8222 2751
8222 5398
Level 5 Allied Health Bg
Level 5 Emergency Block
8222 5524
8222 5185
8222 5924
8222 5989
Surgical Oncology
Thoracic Medicine
Chest Clinic
8222 5286
8222 5398
Thyroid/Parathyroid
Urology
Level 9 Outpatient Block
8222 2923
8222 5928
Level 5 Emergency Block
8222 5185
8222 5989
Vascular
Level 5 Emergency Block
Level 5 Allied Health Bg
8222 5185
8222 5524
8222 5989
8222 5924
Voice Clinic