Referral Letter Template

[CLINIC / PRACTICE LETTERHEAD]

Date: [Date]

TO:
Dr Ales Aliashkevich
Neurosurgeon & Spine Specialist
HealthLink EDI: mineuro
Email: referrals@mineuro.com.au
Fax: +61 3 9000 0000

RE: NEUROSURGEON REFERRAL
Patient Name: [Patient Full Name]
Date of Birth: [DD / MM / YYYY]
Patient Phone: [Patient Phone Number]
Patient Address: [Patient Home Address]
Medicare Number: [Medicare Number & Reference]

Dear Dr Aliashkevich,

I am writing to refer this patient for specialist neurosurgical assessment regarding:
[  ] Suspected Spinal Stenosis / Neurogenic Claudication
[  ] Cervical/Lumbar Radiculopathy (Leg or Arm Pain)
[  ] Suspected Cervical Myelopathy / Cord Compression
[  ] Suspected Intracranial Lesion / Cranial Tumour
[  ] Brain Aneurysm / Vascular Lesion Screening
[  ] Other: [Specify clinical reason]

CLINICAL HISTORY & SYMPTOMS:
- Symptom Duration: [Days/Weeks/Months]
- Pain Location & Score: [e.g., Axial low back pain, radiating down L5 dermatome. Pain 8/10]
- Progressive neurological changes: [e.g., foot drop, hand clumsiness, gait imbalance]

PHYSICAL EXAMINATION FINDINGS:
- Motor Deficit: [e.g., L5 dorsiflexion 4/5 weakness]
- Sensory Changes: [e.g., Numbness over lateral lower leg]
- Reflexes: [e.g., Knee jerk 2+ bilateral, ankle jerk trace on left]
- Bowel/Bladder Changes: [e.g., Checked for red flags. Bladder/bowel sensation and function intact]

PREVIOUS TREATMENTS ATTEMPTED:
- Physical Therapy: [Details of rehab / exercise tried]
- Medications: [NSAIDs, Gabapentin/Pregabalin, Corticosteroids, etc.]
- Spinal Injections: [e.g., Epidural corticosteroid injection performed on DD/MM/YYYY]

DIAGNOSTIC IMAGING PERFORMED:
- MRI Scan: [Date / Provider / Findings - e.g., L4/5 central canal stenosis]
- CT Scan: [Date / Provider / Findings]
- Plain X-Rays: [Date / Provider / Findings]

Thank you for reviewing this patient. I look forward to your specialist recommendations.

Yours sincerely,

Dr. [GP Full Name]
Provider Number: [Provider Number]
Clinic Name: [Practice Name]
Contact Phone: [Clinic Phone]
Contact Fax: [Clinic Fax]