<<Miscellaneous:Practice Letterhead>>

<<Miscellaneous:Date>>

Team Care Coordinator referral
Refer to: Team Care Coordination (MM4030000FT)

RE:<<Patient Demographics:Full Details>>
Medicare Card: <<Patient Demographics:Medicare Number>>
Pension Number: <<Patient Demographics:Pension Number>>  <<Patient Demographics:Medicare Expiry Date>>

Reason for referral: <<Reason for referral>>

History List

<<Clinical Details:Allergies>>
<<Clinical Details:Family History>>
<<Clinical Details:History List>>
<<Clinical Details:Medication List>>
<<Clinical Details:Social History>>

Kind Regards,

<<Doctor:Name>>
<<Doctor:Provider Number>>