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 advice request: [Text]
Date of Onset: [Date]
Priority: [Advice Only]
If the patient has previously been seen by, or a letter has been sent to, this specialty, please provide details including date (where possible).
Patient last seen by this specailty: [Text]