Level 1, 247 Wellington Street, 
Launceston 7250
P: 03 6388 9284 F: 03 6380 8376 
Health link ID: lmc32lmc
E: info@launcestonwhc.com.au
www.launcestonwhc.com.au

Launceston Women’s Health Clinic Referral
Date:
Patient Details
Name: <PtFullName>
DOB:<PtDoB>
Mobile no. 	<PtPhoneMob>						Home no.<PtPhoneH>
Email address:<PtEmail>

Thank you for seeing <PtFirstName> for assessment / assessment and management.  (please indicate)

Reason for referral: free text

Allergies:<Reactions>

Medications:<SelectedRx>

Relevant investigations:<Ix>

Referrer details
Name: <UsrName>
Address:<UsrAddress>
Phone: <UsrPhone>
Health Link code: