Acclario PAH eConsult – Diabetes and Endocrinology

This is a secure transmission directly to the PAH.

Required fields are marked with an asterisk (*).

General Practitioner Information

GP Name*

First Last

GP provider no.

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Position seeking advice

GP Contact Number

GP Email*

Practice Information

Practice Name

Practice Address

Street Address Suburb State Postcode

Patient Information

Patient Name*

First Last

Patient URN

Patient Sex*

Male
Female
Indeterminate

Patient Date of Birth*

Patient Contact Number*

Patient Address*

Street Address Suburb State Postcode

Question

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Category

What is your Clinical Question? (1000 character limit)*

Please do not provide any information in this section which identifies the patient (eg. First/last name, date of birth, address)

Consent for photos obtained from patient or substitute decision maker?

Consent is required if you are attaching photos

Yes
No

Photos and Additional Documents (8MB maximum file size. If uploading multiple photos and documents, make sure that file names are different)

Drop files here or

Accepted file types: jpg, jpeg, gif, png, pdf, docx, rtf, xlsx, Max. file size: 40 MB.

Consent*

I can confirm that I have obtained patient consent for this service and have advised the patient that a medical record will be created for them at the Princess Alexandra Hospital if one currently does not exist.

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