MULTIDISCIPLINARY CARE MEETING
PATIENT REFERRAL FORM
1. PATIENT DETAILS
MIDDLE
INITIAL:
AFFIX STICKER
SURNAME:
FIRST NAME:
TOWN:
D.O.B:
INPATIENT?
Yes / NO Please circle
LRH
BRHS
CGHS
WGHS
GSHS
URL:
2. YOUR DETAILS
FULL NAME:
CLINIC:
3. CONSENT (please tick)
Patient has been given leaflet on Multidisciplinary Care Meetings ‘Information on Treatment and Care
Planning for Gippsland Cancer Patients’ YES  NO 
PATIENT CONSENT
Will be obtained by the
meeting 
Patient has signed a
GRICS MDC consent form
Please fax with referral
form 
Patient has given verbal
consent 
4. GENERAL PRACTITIONER
FULL NAME:
CLINIC:
5. RADIOLOGY REQUEST
SERVICE
PROVIDER
PROCEDURE
 CT
 CT
 CT
 MRI
 MRI
 MRI
 M’GRAM
REPORT
See note below
 M’GRAM
REPORT
See note below
 M’GRAM
REPORT
See note below
REFERENCE
NUMBER
DATE
OTHER
………………………….
OTHER
………………………….
OTHER
………………………….
Please note:

If you are requesting radiology not from Regional Imaging Gippsland (RIG), the radiology report (if available)
will be attached to the MDC meeting agenda.

Mammograms will not be discussed or displayed at the MDC meeting by RIG. If possible, the report will be
made available for the MDC meeting.
6. PATHOLOGY REQUEST
SERVICE PROVIDER
GIPPSLAND PATHOLOGY 
DATE
REFERENCE NUMBER
OTHER  …………………..
Please note:

If you are requesting histopathology not from Gippsland Pathology, the pathology report (if available) will be
attached to the MDC meeting agenda.
7. MDC MEETING
SURGICAL (every Friday 0800-0845)

HAEMATOLOGY (every 4th

Thursday 1730-1815)
8. CANCER STREAM
COLORECTAL

BREAST

UPPER GI

SKIN

LYMPHOMA

LEUKAEMIA

MULTIPLE MYELOMA

OTHER

*** FAX TO 5128 0198 a minimum of 72 business hours prior to scheduled meeting. ***
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MDC REFRRAL FORM INFORMATION AND REQUIREMENTS
The main aims of Gippsland Regional Integrated Cancer Services (GRICS) Multidisciplinary Care (MDC) meetings
are to provide clear pathways for patient referral, develop evidence-based standards of care and assist in reducing
variations in care for Gippsland cancer patients.
REFERRALS
1.
The referring clinician will obtain the patients’ informed consent prior to the meeting. The consent may
be either written or verbal. Informed consent will be supported by a GRICS MDC Patient Information
Brochure, which is available at www.gha.net.au/grics or by contacting GRICS (5173 8502).
2.
All newly diagnosed cancer patients either residing or receiving their care within the Gippsland region
should be referred through to an MDC team meeting. This is inclusive of Gippsland patients diagnosed
within our region but expecting to receive their care at a health service within another region.
3.
Late inclusions to the agenda will not be accepted. Cases referred less than 72 hours prior to the
scheduled meeting will not be included in the agenda and shall be held over until the following week’s
meeting.
RESULTS
1.
GRICS will make requests on behalf of the presenting Multidisciplinary team member for investigation and
diagnostic results to the respective diagnostic services at least 72 hours preceding the meeting.
2.
Clinicians requesting results must include the requesting doctor’s name, the patient’s full
name and date of birth, medical record number, test procedure and date.
3.
Radiology will be provided via the Regional Imaging Gippsland database. Pathology will
be provided in either digital format, slides or by a report.
PROPOSED MDC PATIENT TREATMENT PLAN
1.
The proposed MDC Treatment Plan will be faxed to the referring clinician to sign and fax back to GRICS (03
5128 0198). The proposed MDC Patient Treatment Plan will be stored on the MDC Management System, at
www.gricsmdc.com.au.
2.
Multidisciplinary team members can access an E-patient treatment plan via the MDC Management System at
www.gricsmdc.com.au.
3.
The patient treatment plan will be faxed to the patients’ General Practitioner as a record of the discussion at
the MDC meeting.
4.
When private patients are presented at a multidisciplinary meeting, it is the responsibility of the treating
clinician to record team recommendations in the patient notes.
MEETING POINTS



Bairnsdale Regional Health Service
Central Gippsland Health Service
Latrobe Regional Hospital

West Gippsland HealthCare Group
Other sites are available upon request.
DISCLAIMER
Gippsland Regional Integrated Cancer Services will not be held responsible for medical professionals
failing to obtain patient consent before bringing the patients’ case to the GRICS MDC team meetings.
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