E-Referral for telehealth haematology appointment

To Dr Karan Makhija

Patient Information

First Name *

Last Name *

Date of Birth:

Contact No. *

Patient e-mailPatient e-mail will be used to send information about their appointment and telehealth instructions

Patient Address

This is a telehealth clinic requiring an audio and visual connection. If your patient does not have access to a smart device AND a stable internet connection, we will not be able to give them an appointment.

Reason for referral

Does the patient or a family member have access to a smartphone/tablet/computer WITH stable internet

YesNo

Cytopenia (Hb 80-110, Plt 50-140, Neutrophils 1.0 - 1.9)

Paraprotein

Thrombocytosis/Polycythaemia/Leucocytosis

Thrombosis/Perioperative issue

Lymphocytosis

Other

Clinical Notes

Please include relevant investigation results with the referral or send to our practice via e-mail (admin@cloudclinic.com.au) or fax (02 9190 5381). This is important for the patient's appropriate triage and to answer your clinical question.

Please attach relevant investigations

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Referrer Details

Doctor's Full Name *

Provider No. *

Date: *

Phone no.

Referrer E-mail

Address:

GP Practice Address

Send correspondence to GP? *

YesNo

GP Name

The patient is aware of this referral and consents for us to contact them for a telehealth appointment *

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