Referral Form

A confirmation letter will be sent directly to the patient once an appointment has been made.

Note: * indicates required field.

* Patient Name

* Contact Number

* Date of Birth

* Address

Cardiology

Dr Aiden O’Loughlin

Obstetric Hypertension

Prof Hennessy

Rheumatology

Dr K Pile

Dr A Kelly (Camden Hospital Only)

Dr N Kamalaraj

Referrer’s details:

* Clinician Name

* Clinician Practice

* Provider No

* Contact Phone

* Clinician Email

Clinical Information:

* Clinical Symptoms/Presentation

Any diagnostic testing or blood test results

Provisional Diagnosis

If an appointment is available earlier with another clinician of the same speciality or more appropriate clinician, would you like this patient to be booked in for an earlier appointment?

Yes No

NSW Ministry of Health |

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