Clinical Referral Letter Template

Referral letter: referrer and recipient, urgency, question for specialist, history, medications, investigations, attachments

SantéLégerreferral letterMis à jour 20 oct. 2026

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Mode d'emploi: Use when referring a patient to a specialist or another service. Put the specific question and urgency first. Main pitfall: no clear question, so the recipient cannot triage; send only through approved secure channels.

Aperçu

Referral Letter: [Patient ID placeholder] to [Specialty]

Referral letter from one clinician to another: who is referring to whom, the patient, the reason and urgency, relevant history, medications, investigations and the specific question for the specialist. Based on common clinical correspondence practice. This is a documentation format, not clinical advice. Use placeholders only in this template, and follow local privacy law (for example HIPAA or GDPR) and your institution's policy for sending patient information securely.

Field	Value
Date	YYYY-MM-DD
From	[Referrer name, role, practice or service, contact]
To	[Recipient name or service, specialty, address]
Patient	[Patient name], [date of birth], [MRN / health number]
Patient contact	[Phone, preferred language, interpreter needed: yes / no]
Urgency	[Emergency / urgent / routine]

Reason for referral

Dear [Dr / colleague / service name],

Thank you for seeing this patient. I am referring them for [assessment / investigation / management / procedure] of [problem].

Question for the specialist: [Specific question you want answered.] Example: Please assess for suitability for [procedure] and advise on further investigation of [finding].

Urgency and reason: [Why this level of urgency, for example red flag features present or symptoms progressing.]

Relevant history

[Brief history of the presenting problem: onset, course, treatments tried and their effect, current impact on function.]

Relevant past medical history:

[Condition, year]
[Condition, year]

Current medications and allergies

Medication	Dose and frequency
[Medication]	[Dose, frequency]
[Medication]	[Dose, frequency]

Allergies: [substance and reaction, or "no known drug allergies"].

Investigations

Test	Date	Result
[Test]	YYYY-MM-DD	[Result]
[Imaging]	YYYY-MM-DD	[Key finding]

Patient understanding and preferences

The patient [agrees to this referral / has been informed]. They understand the reason as [summary]. Preferences or needs: [mobility, communication, preferred site or times].

Attachments

[Recent results report]
[Imaging report]
[Previous correspondence]

Please contact me at [phone or secure message route] if you need further information.

Yours sincerely,

[Name], [role], [registration number] [Practice or service]

Standard and licence note

Based on common clinical correspondence practice for referral letters. This is a documentation format, not clinical advice; follow local privacy law and your institution's policy for sharing patient information. Template licence: MIT.

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