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: <<Miscellaneous:Date>>	Practice name: <<Practice/Location:Name>>	
GP name: <<Doctor:Name>>	Provider number: <<Doctor:Provider Number>>	
Address: <<Doctor:Address Line 1>>, <<Doctor:City>>, <<Doctor:State>>, <<Doctor:Postcode>>	
Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	Email: <<Doctor:E-mail>>	

PATIENT INFORMATION	
Family name/s: <<Patient Demographics:Surname>>	Given name/s: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>	
Gender: <<Patient Demographics:Gender>>	Date of birth: <<Patient Demographics:DOB>>	
Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Home phone: <<Patient Demographics:Phone (Home)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	
Email: <<Patient Demographics:E-mail>>	
Preferred means of communication: <<Patient preferred means of communication >>	
Medicare number/ ref: <<Patient Demographics:Medicare Number>>	Pension number: <<Patient Demographics:Pension Number>>	
Marital status: <<Patient Demographics:Marital Status>>	Aboriginal or Torres Strait Islander: <<Patient Demographics:ATSI>>	
Birthplace: (Australia/ other) <<Birth place: (Australia/ other)>>	Preferred language: <<Preferred language:>>	
Interpreter required: <<Interpreter required?>>	Interpreter language: <<Interpreter language:>>	

POINT OF CONTACT (if not client)	
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	
<<Consent>>

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

RELEVANT EXAMINATION FINDINGS (Blood pressure mandatory)	
<<Relevant examination findings (Incl. blood pressure)>>
<<Summary:Investigation Results (Selected)>>	

PREVIOUS COGNITIVE ASSESSMENT RESULTS (MoCa is mandator)	
Date	Type	Score	

PAST MEDICAL HISTORY	
<<Clinical Details:History List>>	

FAMILY HISTORY (including dementia)	
<<Clinical Details:Family History>>	

SOCIAL HISTORY (including history of alcohol)	
<<Clinical Details:Social History>>
<<Clinical Details:Alcohol>>	
Note: We require abstinence from alcohol for 2 weeks prior to assessment if alcohol induced cognitive change is suspected.	

MEDICATIONS	
<<Clinical Details:Medication List>>	

ALLERGIES	
<<Clinical Details:Allergies/Adverse Reactions>>	

INVESTIGATIONS REQUIRED BEFORE REFERRAL IS SENT 
** Please copy The ISLAND Clinic into any pathology or radiology requests	
Pathology:	
•	FBC and Iron Studies	•	UEC/ LFT	•	Random Glucose	
•	HbA1C (if diabetic)	•	TFTs	•	B12 and Folate	
•	U/A -MSU	•	CRP/ESR	•	Calcium/Phosphate/Magnesium	
•	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: GPO Box 341, 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