REFERRAL LETTER

[Clinic name]
[Address]
[Phone and fax]

Date: [Date]

To: [Name of specialist or service]
[Clinic or hospital, address, fax or e-referral destination]

Re: [Patient's full name]
Date of birth: [Date]
Health insurance number: [Number]
Contact: [Patient's address and phone]
Language and access: [Preferred language, interpreter, mobility or other needs]

Dear [Dr. name or colleague],

Thank you for seeing [patient name], age [age], whom I am referring for [reason for referral].

Urgency: [Routine, urgent, or emergent, and why]
My question: [What you want answered: assessment, diagnosis, a procedure, management advice, or transfer of care]

History of the problem: [Onset, course, key symptoms, and red flags present or absent]
Examination: [Relevant findings]
Investigations: [Results with dates; reports attached]
Treatment so far: [What has been tried, with doses, duration, and response]
Past medical history: [Relevant conditions and surgeries]
Medications: [Name, dose, and frequency]
Allergies: [Drug and other allergies, with reactions]
Social context: [Living situation, work, caregiver, anything that affects attending]

[Patient name] knows about this referral and agrees to it. [Their preferences or concerns, if any]

Attached: [Reports, imaging, letters]

Please contact me at [phone or email] if you need more information.

Sincerely,

[Your name, credentials]
[Practitioner or billing number, if required]
[Signature]