The ISLAND Clinic GP Referral Form
HealthLink: utasisla			Fax: 6226 4385		

Patient eligibility and further details on how to refer can be found on our website https://islandclinic.utas.edu.au/referral/ or by calling (03) 6226 4862.
Essential investigations required as part of this referral can be found in the final section of this form. 
An appointment will only be made once all sections of this referral have been completed. 	

REFERRER DETAILS 	
Date: <TodaysDate>	Practice name: <Practice>	
GP name: <UsrName>	Provider number: <DrProviderNo>	
Address: <DrStreet>, <DrCity>, <DrState>, <DrPostcode>	
Phone: <UsrPhone>	Fax: <UsrFax>	Email: <DrEmail>	

PATIENT INFORMATION	
Family name/s: <PtSurname>	Given name/s: <PtFirstName> <PtMidName>	
Gender: <PtSex>	Date of birth: <PtDoB>	
Address: <PtStreet>, <PtCity>, <PtPostcode>	
Home phone: <PtPhoneH>	Mobile: <PtPhoneMob>	
Email: <PtEmail>	
Preferred means of communication: <Patient preferred means of communication (sms/phone/post/email)>	
Medicare number/ ref: <PtMCNo> <PtMCLine>	Pension number: <PtPensionNo>	
Marital status: <PtMaritalSt>	Aboriginal or Torres Strait Islander: <PtEthnicity>	
Birthplace: (Australia/ other) <Birthplace (Australia/other)>	Preferred language: <Preferred language>	
Interpreter required: <Interpreter required>	Interpreter language: <Interpreter language>	

PERSON who will accompany client to clinic	
Family name/s: <Surname of carer (if applicable)>	Given name/s: <Firstname of carer (if applicable)>	
Address: <Address of carer (if applicable)>	
Home phone: <Carer home phone>	Mobile: <Carer mobile phone>	
Email: <Carer email>	
Relationship: <Carer relationship>	Availability: <Carer availability>	

CONSENT	
I confirm the client has been made aware of the referral:  <Client has been made aware of the referral:>	
I confirm that the client is aware that The ISLAND Clinic is a research based interdisciplinary assessment and diagnostic clinic and that some of this assessment may occur using Telehealth: <client is aware that The ISLAND Clinic is a research based interdisciplinary assessment and diagnostic clinic and that some of this assessment may occur using Telehealth:>	

HISTORY OF THE PRESENTING COMPLAINT (onset/ duration/ symptoms of memory/ cognitive issues)	
<Hx of presenting complaint (include onset/duration/symptoms of memory/cognitive issues>	

RELEVANT EXAMINATION FINDINGS (Blood pressure mandatory)	
<Relevant examination findings (blood pressure  mandatory)>

PREVIOUS COGNITIVE ASSESSMENT RESULTS (at least one is mandatory: MoCa, MMSE, GP-cog etc)	
Date	Type	Score	

PAST MEDICAL HISTORY	
<SelectedPMH>	

FAMILY HISTORY (including dementia)	
<FamilyHx>	

SOCIAL HISTORY (including history of alcohol)	
<SocialHx>
<AlcHx>	

MEDICATIONS	
<SelectedRx>	

ALLERGIES	
<Reactions>	

INVESTIGATIONS REQUIRED BEFORE REFERRAL IS SENT 
** Please copy Dr Katharine Salmon at The ISLAND Clinic into any pathology or radiology requests	
Pathology:	
•	FBC	•	UEC/ LFT	•	Random Glucose	
•	HbA1C (if diabetic)	•	TFTs	•	B12 and Folate	
•	U/A -MSU	•	CRP/ESR	•	Calcium/Phosphate	
•	Lipids	•	Syphilis and HIV	•	Other pathology if thought applicable	
Please attach ECG if done in the last 6 months	
Imaging:	
•	CT/MRI scan report(s) if done in preceding 6 months	
*NOTE: The ISLAND Clinic Specialist will refer the client for an MRI brain scan after triage* 	

Please send completed form via HealthLink to utasisla, or fax to (03) 6226 4385 if HealthLink not available. Can also post to The ISLAND Clinic, Private Bag 143, Hobart, TAS, 7001
Clinics are held every Wednesday on site or via a series of telehealth / selected site visits. You and your client will be informed of the appointment date. 
You will receive a comprehensive written summary and management plan on completion of the assessments. If you have any queries, please call (03) 6226 4862 or email ISLAND.clinic@utas.edu.au