Request for Renal Specialist Outpatient Appointment
Please complete referral letter overleaf. To move from one field to the next, please use the “tab” key
HOSPITAL
SPECIALTY / CLINIC
Renal
NAME OF SPECIALIST
PREFERRED
Has the patient previously been seen by this hospital?
Yes
No
Has the patient previously been referred to the renal clinic / speciality
Year
Yes
No
PATIENT DETAILS
Medical Record Number (if known)
Please tick if applicable for this referral:
DVA White
DVA gold
Medicare Number:
Date of Birth:
Ref No:
/
Male
/
Country of Birth:
Marital Status:
Number:
Married
Single
Widow
Female
Aboriginal
Torres Strait Islander
Divorce
Separated
Surname:
Previous surname
First names:
Preferred Name/Title
Neither
Defacto
(i.e. maiden name):
Address:
Mailing Address (if different)
Phone: home
Work:
Mobile:
Next of Kin (Essential if under 18 years/guardian)
SPECIAL NEEDS
Relationship:
If interpreter required, specify language & dialect
First Name:
Surname:
Other special needs:
Phone:
Mobile:
REFERRING DOCTOR
LENGTH OF REFERRAL
Name:
12 months
Address:
Other
REFERRAL RECOMMENDATION
This patient needs to be seen (please indicate
Postcode:
Routine
Phone:
Urgent
Fax:
or CPAC category 1,2, 3, 4, 5 (please indicate)
USUAL GP: as above
Other
(see below)
Have discussed with Registrar/Consultant)
Name (if known)
Name:
Suburb:
Appointment date given: (if applicable)
Yes
/
No
/
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Referral Letter for Renal Disease
REASON FOR REFERRING (Please tick more than one if applicable from the list below)
Immediate referral (Contact Renal Service via Hospital Switchboard)
Malignant hypertension
Hyperkalaemia (K>7.0mmol/l)
eGFR <15ml/min
Acute Renal Failure and Systemic Illness
Urgent referral (Category 1 <30 days)
Acute Nephrotic Syndrome (Proteinuria>300mg/mmol),
oedema & low serum albumin
Suspected systemic illness, eg SLE with renal
involvement.
Unexplained or Symptomatic eGFR 15–29ml/min
Routine referral (Category 2 = 30 – 90 days)
Suspected Glomerulonephritis: e.g
Proteinuria/haematuria (urine PCR >100mg/mmol)
eGFR 15–29ml/min (clinically well or known
diagnosis)
eGFR 30–59ml/min and:
indigenous with diabetes*
eGFR <60ml/min and eGFR decline >10% in 2
months*
Anaemia (Hb <100g/l)*
Abnormal potassium, calcium or phosphate*
uncontrolled hypertension on 3 agents including a
diuretic*
Routine referral (Category 3 = 90 – 365 days)
eGFR 30–59ml/min with >10% decline in 6 months
Additional Diagnoses
eGFR >60ml/min and suspected renal disease
Other Conditions:
o Diabetes mellitus:
No
Yes
o Hypertension:
No
Yes
o Cardiac disease
No
Yes
o Peripheral vascular disease
No
Yes
Smoking Status:
Body Weight:
Creatinine:
eGFR
Current medications:
OTHER REASONS/COMMENTS for REFERRAL. Attach other information for eg drug allergies or reactions with
patient’s name and DoB clearly printed :
PLEASE ATTACH COPIES OF ALL CURRENT RELEVANT INVESTIGATIONS / REPORTS/ LETTERS
Doctor’s Signature
Provider Number
Date
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