The Menzies Blood Pressure Clinic
Private Bag 23, Hobart  TAS 7001
Tel: 03 6226 4710
Fax: 03 6226 7764
Email: Menzies.BPClinic@utas.edu.au	

Menzies Blood Pressure Clinic Referral Form	

For the referral of patients with difficult to treat hypertension for further assessment and management recommendations. All our services are bulk-billed. Please return completed referral form by fax, post or email.
 
This form is also available electronically as a template for Medical Director and Best Practice software from Tasmania Medicare Local (www.tasmedicarelocal.com.au/search/node/menzies).

  Referring Doctor Details						Referral Date:  <TodaysDate>

Name:	 <DrName>	Provider:	 <DrProviderNo>	
Practice:	 <Practice>			
Address:	 <DrStreet>			
City/Suburb: 	 <DrCity>	Post code:	 <DrPostcode>	
Phone:	 <DrPhone>	Fax:	 <DrFax>	

  Patient Demographic Information

Name:	 <PtName>	 Date of Birth:	  <PtDoB>	
	 	 Gender:	 <PtSex>	
Address:	 <PtStreet>			
City/Suburb:	 <PtCity>			
State:	 <PtState>	 Postcode:	 <PtPostcode>	
				
Phone - (h):	 <PtPhoneH>	 Phone - (w):	 <PtPhoneWk>	
Phone - (m):	 <PtPhoneMob>	email: 	 <PtEmail>	

Health Summary Report

 Please provide a brief summary of the Patient's health:

 Latest Clinical BP Measurements

 <Observations>

 Allergies, reactions and other pertinent information

 <Reactions>	

 InvestigationResults  pertaining to target organ damage / secondary hypertension (i.e. renal function tests, echocardiography, ECG, urine ACR, other relevant tests). 

 <Ix>