Patient Details
Name	<PtPrefName> <PtSurname>	
Medicare name	<PtFullName>	
Gender assigned at birth	<PtSex>	
Gender identity	<GenderIdentity>	
Pronouns	<Pronouns>	
DOB	<PtDoB>	
Medicare number (if applicable)	<PtMCNo>, <PtMCLine>, exp. <PtMCExpiry>	
Address	<PtAddress>	
Phone	<PtPhoneMob>	
Email	<PtEmail>	

Clinical Details & Examination

Allergies <Reactions> 
Medications <SelectedRx>
Medical history <SelectedPMH>
Blood pressure
<Recent BP (& date):>
BMI
<BMI (only if patient consents/ leave blank if declines or not appropriate for patient)>
Other relevant information
<Any other relevant information>

Ongoing care (please tick one)

<ONGOING CARE: I am referring for gender affirming hormonal care and can continue care once initiated/stablised if I am provided with a plan for medication titration and management, OR> I am referring for gender affirming hormonal care and can continue care once initiated/stablised if I am provided with a plan for medication titration and management 
<I am referring for all/ ongoing gender affirming hormonal care needs and am able to provide ongoing other primary health care needs for this patient>I am referring for all/ ongoing gender affirming hormonal care needs and am able to provide ongoing other primary health care needs for this patient

Referring GP & contact details
<DrName>
<DrQualifications>
<DrAddress>
Phone: <DrPhone> Fax: <DrFax>	GP Stamp