Patient Details	

Patient Name:	  <PtName>	
Postal Address:	  <PtPOAddress> <PtCity>	State:	  <PtState>	Post Code:	  <PtPostcode>	
Date of Birth:	  <PtDoB>	Phone Number:	  <PtPhoneH>	
Medicare Number:	  <PtMCNo>	Private Health Number:		

Clinical Details	

Medical History / Medications:
<SelectedRx>

Specific Clinical Query?

 Urgent	

Consultation	

 Dr Robert Tewksbury
      Vascular & Endovascular Surgeon

Referring Doctor	

Name: <DrName>	Provider Number: <DrProviderNo>	

Signature: _____________________	
Date: <TodaysDate>	
Practice Name: <Practice>	Contact Number: <UsrPhone>	
Health Link EDI: 		

Copy of the report to: ________________________________________

Please ensure Access Vascular receives a copy of Patient Discharge Summaries

Locations	

Joondalup
Suite 6 (Ground Floor)
Sanori House
126 Grand Boulevard
Joondalup WA 6027	Cottesloe
3/40 Marine Parade
Cottesloe WA 6011
(Located in Soleil Health Medical Centre)