REFERRAL LETTER

HEADER
To:
From:
Date:
Patient name, date of birth and record number:

QUESTION
Question:

URGENCY
Urgency:
Reason:

HISTORY
History of presenting complaint:
Relevant past history:
Risk factors:

MEDICATIONS AND ALLERGIES
Medications and doses:
Allergies and reactions:

RESULTS
Result, value, unit and date:

WHAT I HAVE DONE
Investigations arranged:
Treatment started or stopped:
What I would like you to take on:

PATIENT AND SAFETY NET
What the patient knows:
Communication needs:
Safety-netting advice given: