REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL
RESPIRATORY and SLEEP CLINICS
Dr Siva P Sivakumaran
Dr Iain Feather
Dr Toby Tang
SEND TO:
Dr Sivakumaran (Director of Respiratory Med.)
Dr Maninder Singh
Dr Krishna Sriram
FROM: «docname»
«sitename»
«siteaddr1»
«siteaddr2»
«siteaddr3»
Phone: «sitephone»
Fax: «sitefax»
Email: practice@rtmc.com.au
Provider Number: «docprov»
GC Hospital Bookings & Referrals Centre
Fax: 5519 8448 OR
Post: 2nd Floor/108 Nerang Street
Southport QLD 4215 OR
Secure transmission service via Medical Objects
Signature
Grading criteria’s of the new Respiratory referrals.
Cat 1 – Lung cancer, Haemoptysis, Acute interstitial lung disease, Life threatening OSA, Idiopathic PAH, and < 1cm
pulmonary nodule to the general respiratory clinic
Cat 2 – All other respiratory referrals.
Cat 3 – Chronic cough with negative imaging
Date: «datel»
Dear Dr Sivakumaran,
RE: «patientfullname»
Date of Birth: «dob»
Interpreter Required? NO:
YES:
If Yes – LANGUAGE?:
Street Address:
«address1»
«address2»
«address3»
Home Phone No: «phoneh»
Mobile Phone No: «phonem»
Alternative Contact Name:
Alternative Contact Phone No:
[Alternative contact may be used to contact the patient if they cannot be reached via the contact details given]
Medicare No: «medicareno»
(Medicare ineligible patients will incur an appointment fee)
Do you identify as being of Aboriginal or Torres Strait Islander origin? Yes
No
Reason for Respiratory / Sleep Referral: [Please ensure this information is supplied]
Include as much relevant information as possible about your patient's condition to optimise their
chances of being triaged correctly eg diagnosis, duration, severity and impact.
Problem:
Duration:
Severity:
Impact:
**Clinical History is noted on last page**
Developed in partnership by General Practice Gold Coast and Gold Coast Health Service District Sep 2012
Please Ensure Appropriate Pre-Requisite Tests Have Been Performed And Are Attached.
For ALL subsequent tests please arrange a copy to come to Gold Coast Hospital.
General Respiratory: FBC, E/LFTs, Recent and any previous CXR, Spirometry (pre and post
bronchodilator) where relevant, if available
For Sleep Referrals include:

BMI, Occupation and effects on driving, Impact on quality of life or other medical conditions.
For lung cancer arrange:
 CT chest and upper abdomen, including adrenal glands, with contrast for staging
Chronic cough - CXR must be done, with CT if clinically indicated
Results:
Clinical History: (Include Medical History – Allergies – Current Medication)
«printclinicalhistory»
Developed in partnership by General Practice Gold Coast and Gold Coast Health Service District Sep 2012