The Menzies Blood Pressure Clinic
Private Bag 23, Hobart  TAS 7001
Tel: 03 6226 4710
Fax: 03 6226 7764
Email: 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: <<Miscellaneous:Date (short)>>

Name:	 <<Doctor:Name>>	Provider:	 <<Doctor:Provider Number>>	
Practice:	 <<Practice:Name>>			
Address:	 <<Doctor:Address Line 1>>			
City/Suburb: 	 <<Doctor:City>>	Post code:	 <<Doctor:Postcode>>	
Phone:	 <<Doctor:Phone>>	Fax:	 <<Doctor:Fax>>	

Patient Demographic Information

Name:	 <<Patient Demographics:Full Name>>	 Date of Birth:	  <<Patient Demographics:DOB>>	
	 	 Gender:	 <<Patient Demographics:Sex>>	
Address:	 <<Patient Demographics:Address Line 1>>
 <<Patient Demographics:Address Line 2>>			
City/Suburb:	 <<Patient Demographics:City>>			
State:	 <<Patient Demographics:State>>	 Postcode:	 <<Patient Demographics:Postcode>>	
				
Phone - (h):	 <<Patient Demographics:Phone (Home)>>	 Phone - (w):	 <<Patient Demographics:Phone (Work)>>	
Phone - (m):	 <<Patient Demographics:Phone (Mobile)>>	email: 	 <<Patient Demographics:E-mail>>	

Health Summary Report

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

Latest Clinical BP Measurements

<<Clinical Details:Measurements>>

Allergies, reactions and other pertinent information

 <<Clinical Details:Allergies>>	

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

<<Summary:Investigation Results (Selected)>>