PGx Referral Template

Referral Type: Pharmacogenomic (PGx) Testing
Referral Name: Dr Phoebe Slape 
Brain & Mind Hub Sunshine Coast
Level 2, 60-62 Dalton Drive
Maroochydore. 4558
Phone: 0752208793
Fax: 0735234004

Purpose: Request for PGx testing and report delivery to the referring clinician.

Required fields are marked with *.
____________________________________________________________________________
Step 1 | Clinician Details
Full Name *
e.g., Dr Jane Smith
______________________________________________________________
Email Address *
Your practice email - this is where the PGx report will be delivered
______________________________________________________________
Practice Name *
Clinic or practice name
______________________________________________________________
Practice Address *
Street address and suburb
______________________________________________________________
State *
QLD / NSW / VIC / SA / WA / TAS / NT / ACT
______________________________________________________________
Postcode *
4-digit postcode
______________________________________________________________

Step 2 | Patient Details
First Name *
Patient's first name
______________________________________________________________
Last Name *
Patient's last name
______________________________________________________________
Email Address *
Patient's email - where the ordering instructions will be sent
______________________________________________________________
Sex at Birth *
Male / Female / Intersex / Prefer not to say
______________________________________________________________
Height (cm)
Optional - useful context for some dosing recommendations
______________________________________________________________
Weight (kg)
Optional - useful context for some dosing recommendations
______________________________________________________________
Ethnicity
Optional - relevant for allele frequency interpretation in some genes, e.g., HLA-B
______________________________________________________________

Step 3 | Medication History and PGx Testing Context

Medications Under Consideration *
List all medications you are considering prescribing, or specific gene-drug interactions you wish to clarify.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Medications Not Tolerated
Any medications the patient has previously not tolerated, with brief reason if known.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Current & Past Medications
Current medications with doses, plus relevant past medications.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Medication Allergies
Current allergy/adverse drug reaction history, including drug name, reaction and severity
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Additional Clinical Notes
Include any relevant diagnosis, treatment goals, family history of medication issues, smoking status, or clinical context that may assist interpretation of PGx results.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Consent / Confirmation
[ ] Patient has consented to PGx testing and to receiving ordering instructions by email.
[ ] Patient understands the PGx report will be delivered to the referring clinician's nominated practice email.
[ ] Clinician confirms the above information is accurate to the best of their knowledge.

Referring Clinician Signature: ____________________________________________

Provider Number: ________________

Date: ____ / ____ / ______