This is a dictation template to provide a reminder of the information required to complete the referral. The fields in red are mandatory and must be completed on the referral protocol.
Presenting Complaint
Main Presenting Complaint: [Text – 98 character maximum]
Reason for Referral: [Text]
Date of Onset: [Date]
Priority:
- Routine
- Urgent
Priority Reason: [Text – 98 character maximum]
Acne Severity:
- Mild
- Moderate
- Severe nudulocystic