HIS Victoria A4 General Referral Sheet New Version PHCIVFRM0015 01-20 32376 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the appointment time and date at the top of the form. Ensure accuracy as this information is crucial for scheduling.
3. Fill in the clinic name and address where the referral will be sent. This helps streamline communication between healthcare providers.
4. Provide patient details, including their name, date of birth, telephone number, and medical number. Double-check these entries for correctness.
5. In the 'Referral/Request(s) for' section, specify the clinical details and any urgent requests by checking the appropriate boxes.
6. Complete the referring doctor details, including their signature and date. This validates the referral process.
7. Review all sections thoroughly before submitting to ensure all necessary information is included.

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