# 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.

<!--
Guidance: How to use this template
- Put the question and the urgency first. The recipient triages on the
  first few lines.
- Include only information relevant to the referral, and attach results
  rather than retyping them.
- Send through an approved secure channel and record that the patient
  agreed to the referral.
-->

| 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.