CONSULTATION 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]