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Form library · MED-005

Specialist referral intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Rules differ by state; check yours.

Australian specialist rooms taking a referral and the questions they ask before the first appointment.

The person gives contact details, the referring practitioner, and what the visit is for. It is a questionnaire before an appointment. It does not diagnose or recommend treatment.

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Specialist referral intake

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.

Example only. Fictional rooms: Example Specialist Rooms, Subiaco. This is a questionnaire before an appointment, not a diagnosis.

DD/MM/YYYY

Privacy: Example Specialist Rooms collects this information to provide your care. We may share it with the people who treat you. Read our privacy policy at example.com/privacy. Example only: the practice must write its own collection notice. See GEN-002.

Fields

  • Person

    Name, date of birth, mobile and email.

  • Referring practitioner

    Who sent them. Write Self if there is no referral.

  • What the visit is for

    In their own words.

  • What they want to cover

    In their own words.

  • Consent

    The rooms may use the answers to prepare for the appointment.

  • Collection notice

    A line the practice writes before anyone uses the form.

Questions

Does this book the appointment?

No. It collects what the referral is for. The rooms confirm the time.

Is this a diagnosis?

No. It is a list of questions before an appointment. It does not diagnose or recommend treatment.

About these templates

These templates are examples only, to help you get started. They are general information, not legal, medical, clinical or professional advice, and they may not suit your business, your profession or your state or territory.

Before you use any template, you must review and adapt it, and have it checked where needed, so it fits your services, your professional body's rules, privacy and health records laws, and the law where you operate. This matters most for consent, waiver, privacy and minors' forms. You are responsible for the forms you use and the information you collect.

To the extent the law allows, nopen gives no warranty that the templates are complete, current or fit for any purpose, and is not liable for loss arising from their use. Nothing here excludes, restricts or modifies any right or remedy you have under the Australian Consumer Law that cannot lawfully be excluded.

The templates are not endorsed by or connected with any government agency, including Services Australia, Medicare or the NDIA. Do not add government logos, the Commonwealth Coat of Arms or other official marks to them. Fields that refer to government numbers (such as a Medicare card number) are labels only.

Example only. Not legal or clinical advice. Review and adapt before use. Not endorsed by any government agency. This example has not had a separate legal review.