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Consultation Letter Template
A consultation letter is the specialist’s reply to a referral: what you found, what you think, and what happens next. Answer the question you were asked, and name who does each next step, so nothing falls between you and the referring clinician.
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- Word and text downloads
- Two filled examples
Blank consultation letter template
FreeCONSULTATION LETTER [Clinic or department name] [Address] [Phone and fax] Date: [Date of letter] To: [Referring clinician's name] [Clinic, address, and fax or secure email] Copies to: [Primary care provider, if not the referring clinician, and anyone else with a part in the plan] Re: [Patient's full name] Date of birth: [Date] Health insurance number: [Number] Seen on: [Date or dates of the consultation] Dear [Dr. name or colleague], Thank you for your referral of [date of referral] about [patient name], age [age], whom I saw for [reason for referral]. Your question: [The question asked in the referral] In short: [Your answer in one or two sentences, and the main next step] History: [The history of the problem, what has changed since the referral, and relevant past history] Medications: [Current medications, with doses] Allergies: [Drug allergies, with reactions] Examination: [Relevant findings] Investigations: [Results reviewed and tests done at the visit, with dates] Impression: [Diagnosis or differential diagnosis, and the findings that support it] Treatment: [Medications started, changed, or stopped, with dose, frequency, and the reason for each] Pending: [Tests and referrals still outstanding, why, when they are due, and who will follow up each result] Advice given to the patient: [What you explained, the warning signs, and when to call 911 or go to the emergency department] Follow-up plan: I will: [What you will arrange, review, or see the patient for, and when] Please: [What you ask the referring clinician to do or monitor, and when] Ongoing care: [Whether you will keep seeing the patient, for what and for how long, or are returning care to the referring clinician] Please contact me at [phone or email] if you have questions. Sincerely, [Your name, credentials, and specialty] [Practitioner or billing number, if required] [Signature]
Use it for
- Specialist clinics
- Replies to referrals
- Second opinions
- Follow-up reports
- Returning care to the referrer
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Consultation letter from cardiology
Cardiologist to family physician, urgent referral
Reason and question
Thank you for your referral of October 8, 2026. I saw this 59-year-old man on October 20 with 3 weeks of chest tightness on exertion. You asked for my assessment and advice on further testing. In short: this is probably stable angina. I have started treatment and booked a CT coronary angiogram.
History
No change since your referral. Central chest tightness walking uphill or climbing two flights of stairs, easing within 5 minutes of rest. He has used his nitroglycerin spray twice, with relief within 2 minutes each time. No pain at rest, no episode longer than 10 minutes, no palpitations or fainting. Using nicotine patches, and down from 20 to 8 cigarettes a day. Hypertension; father had a heart attack at 54. Aspirin 81 mg daily, ramipril 5 mg daily, nitroglycerin spray as needed. No known drug allergies.
Examination
BP 142/86, HR 76 and regular, BMI 31. Normal heart sounds, no murmurs. Chest clear. Normal peripheral pulses, no leg swelling.
Investigations
Your results of October 12: LDL cholesterol 3.9 mmol/L (151 mg/dL), A1c 5.5%, creatinine 0.9 mg/dL (80 µmol/L). ECG today: sinus rhythm, rate 74, no ST changes, unchanged from October 8. Echocardiogram today: normal left ventricular size and function, ejection fraction 60%, no wall motion abnormality, no significant valve disease.
Impression
Probable stable angina: typical symptoms, with hypertension, smoking, a high LDL, and a family history of early heart disease. Normal resting ECG and heart function. Nothing suggests an unstable pattern, so testing as an outpatient is safe.
Treatment
Continue aspirin 81 mg daily and nitroglycerin spray as needed. Started metoprolol 25 mg twice daily, to reduce angina and to slow his heart rate for the CT. Started atorvastatin 40 mg daily: his risk is high whatever the CT shows. Ramipril unchanged at 5 mg daily for now, as metoprolol will also lower his blood pressure. I have given him prescriptions for 3 months.
Pending
CT coronary angiogram, booked for October 29, 2026, to look for narrowing of the coronary arteries. I ordered it, so I will review the result, tell him, and send it to you with the plan.
Advice given
Explained that this is probably angina, and why we are doing the CT. Nitroglycerin: sit down before using it, and don’t use it if he has taken an erectile dysfunction medicine in the last 2 days. Call 911 if chest pain comes on at rest, lasts more than 10 minutes, or hasn’t eased 5 minutes after one spray. Keep walking at a pace that doesn’t bring on pain. Pull over and stop if pain starts while driving. Stopping smoking is the most helpful step he can take.
Follow-up plan
I will: review the CT result and write to you within a week of it; arrange an invasive coronary angiogram if it shows significant narrowing; see him in clinic in late November. Please: check his blood pressure and heart rate in 2 weeks, and increase ramipril to 10 mg daily if his blood pressure is above target; repeat lipids in 6 to 8 weeks; keep supporting him to stop smoking; renew his prescriptions after 3 months. Ongoing care: I will keep seeing him until his testing is complete and his symptoms are controlled.
Consultation letter from gastroenterology
Gastroenterologist to family physician, routine referral
Reason and question
Thank you for your referral. I saw this 34-year-old woman on October 14, 2026, with 10 months of abdominal pain and loose stools. You asked whether she needs a colonoscopy, and how to manage her symptoms. In short: this is irritable bowel syndrome with diarrhea. She doesn’t need a colonoscopy, and I am returning her care to you with the plan below.
History
Lower abdominal cramping 2 to 3 days a week, eased by a bowel movement, with loose stools 2 to 3 times a day, urgency, and bloating. Worse with stress and after large meals. No rectal bleeding, weight loss, diarrhea at night, or fever. No recent travel or antibiotics. No family history of bowel cancer, celiac disease, or inflammatory bowel disease. No regular medications. No known drug allergies.
Examination
Weight 64 kg (141 lb), unchanged over the past year. Abdomen soft, with mild tenderness in the left lower quadrant. No masses, and no enlarged liver or spleen.
Investigations
Your results of October 2, all normal: complete blood count, ferritin, CRP, TSH, and tissue transglutaminase IgA with a normal total IgA, taken while she was eating gluten. Fecal calprotectin 22 µg/g, normal. No further tests needed.
Impression
Irritable bowel syndrome with diarrhea. She meets the Rome IV criteria and has no alarm features. Normal celiac serology makes celiac disease very unlikely, and a normal calprotectin and CRP make inflammatory bowel disease unlikely. At 34, with no alarm features, a colonoscopy would not change the plan.
Treatment
No prescriptions. Recommended psyllium, 1 teaspoon a day, increased slowly over 2 to 3 weeks; enteric-coated peppermint oil, 1 capsule three times a day before meals, for cramping; and loperamide 2 mg as needed for urgency, such as before a long drive, up to 8 mg a day.
Pending
Referral to our clinic dietitian for a 4 to 6 week low-FODMAP diet, then bringing foods back one at a time. Our clinic books the visit and will send you the dietitian’s notes. No tests pending.
Advice given
Explained the diagnosis: a common problem with how the gut and brain work together, which doesn’t damage the bowel or raise the risk of bowel cancer. Symptoms often come and go. Gave her written information on diet and the 3 medicines above. Told her to see you promptly if she has blood in her stool, weight loss she can’t explain, diarrhea that wakes her at night, or fever.
Follow-up plan
I will: arrange the dietitian visit. No routine follow-up with me; she is discharged from the GI clinic. Please: review her in 3 months. If symptoms still limit her daily life, consider amitriptyline 10 mg at bedtime, raised to 20 or 30 mg if needed and tolerated. Refer her back to me if a warning sign appears, or if she doesn’t improve with treatment. Ongoing care: returned to you.
What goes in each part.
Reason and question
Remind the reader why you saw the patient, and answer their question before the detail.
- The date or dates you saw the patient, and the date of the referral
- The reason for referral, and the question asked, in a sentence
- Your answer and the main next step, in one or two sentences
Avoid: Putting the answer after a page of history. A busy reader may stop before they reach it.
History and findings
What you found that bears on the question. The referring clinician already has their own history.
- What has changed since the referral
- Examination findings that support or rule out the main possibilities
- Results you reviewed and tests you did, with dates
- Current medications and allergies, as you confirmed them
Avoid: Copying the referral letter back to the person who wrote it.
Impression
Your diagnosis, or your leading diagnosis and what else you considered.
- The diagnosis, or a differential with the most likely first
- The findings and results that support it
- What is still uncertain, and what will settle it
Avoid: A list of possibilities with no view on which is most likely.
Treatment
Every medicine you started, changed, or stopped, so the referring clinician can continue it safely.
- Drug, dose, and frequency
- Why you made each change
- Who will renew the prescription, and when
Avoid: “Started a statin” with no drug, dose, or reason.
Pending results and referrals
Anything not yet done, and who acts on it. This is where follow-up can fall between two clinicians.
- Each outstanding test or referral, and why you ordered it
- When it is due
- Who will review the result and tell the patient
Avoid: “Results to follow” with no name next to them.
Advice to the patient
What you told the patient, so the referring clinician can repeat it rather than contradict it.
- What you explained about the diagnosis and the tests
- Warning signs, and when to call 911 or go to the emergency department
- Self-care advice, and any written information you gave
Avoid: Leaving the referring clinician to guess what the patient has been told.
Follow-up plan
Every next step, with one name next to it: yours or the referring clinician’s.
- What you will arrange, review, or see the patient for, and when
- What you ask the referring clinician to do or monitor, and when
- Whether you will keep seeing the patient, or are returning care
- When to send the patient back to you
Avoid: “Follow up as needed.” Say who, what, and when.
Sending it
Acknowledge the referral promptly, and send the letter soon after the visit, sooner if the findings are urgent. Some regulators set deadlines for both, so check yours.
- To the referring clinician and, if different, the patient’s primary care provider
- A phone call first if anything is urgent, then the letter
- A follow-up letter when new findings or a later visit change the plan
- A copy kept in your own record
Avoid: Assuming the referring clinician will read your clinic note. Send the letter, unless you share a record they use.
Common mistakes, and how to avoid them.
No direct answer
If the referral asked a question, answer it near the top. A long history with the answer on page 2 is easy to miss.
Pending results with no owner
Name who follows up each pending test or referral. “Results to follow” leaves each of you thinking the other will act.
Medicine changes without doses or reasons
Give the drug, the dose, and why you started, changed, or stopped it, so the referring clinician can continue it or spot a problem.
Sent late, or not to the primary care provider
Send it soon after the visit, and phone first if anything is urgent. Copy the patient’s primary care provider if they didn’t make the referral.
No update when the plan changes
When a new result or a later visit changes the plan, send a short follow-up letter. The last letter on file should match the current plan.
A draft sent unchecked
Read a dictated or AI-drafted letter before you sign it. If you find an error after it has gone, tell the recipient and send a correction.
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Frequently asked questions.
What should a consultation letter include?
The patient’s and both clinicians’ details, the date seen, the reason for referral and the question, the key history, findings, and results, your impression, treatment started and why, pending tests and who follows them up, the advice you gave, and the follow-up plan.
How do you write a consultation letter to a referring physician?
Restate their question and answer it in the first lines. Then give the findings and results that support your answer, your impression, the treatment, and a follow-up plan that names who does each step.
What is the difference between a consultation letter and a referral letter?
A referral letter asks another clinician to see the patient and answer a question. The consultation letter is the reply: what the specialist found, what they think, and what happens next.
How soon should a consultation letter be sent?
Soon after the visit, and sooner if the findings are urgent. For anything urgent, phone the referring clinician first, then follow up in writing. Some regulators set a deadline, so check yours.
Who follows up on pending test results?
Whoever the letter names, so name someone for each test. Usually the clinician who ordered it reviews the result and tells the patient. If you want the referring clinician to act on a result, ask them, and make sure they receive it.
Do I need to send another letter after a follow-up visit?
Yes, if there are new findings or the plan changes. A short letter is enough: the response to treatment, new results, and the updated plan.
Is this consultation letter template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
Can Vero write a consultation letter from my visit?
Yes. Vero drafts the letter from your visit in your template. Review and edit it, then export it to PDF or Word, print it, or email it.
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Your template. Filled in from the visit.
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