Primary Care Referral/Consult Letter to Specialist

Date: [Date]

Document Type: Referral/Consult Request

From: [Referring clinician name, credentials, specialty, practice name, direct contact]

To: [Specialist name or "Next available [Specialty]", clinic/location if known]

Patient: [Full name, DOB, MRN or other identifier]

Re: [Patient Name], [DOB] — Referral for: [problem] — Urgency: [urgent / subacute / routine]

Referral Request

[One-sentence patient snapshot: age, sex, and only comorbidities that materially affect this referral]

Clinical Question: [Explicit clinical question(s) as direct requests, e.g., "Please evaluate for...", "Please advise whether...", "Is [diagnosis] likely and what workup do you recommend?"]

Urgency: [urgent / subacute / routine] — [Brief justification including time course, severity, and any red flags driving urgency]

Referral Type: [eConsult/advice-only / consultation (PCP retains management) / procedural consult / co-management / transfer of care]

Clinical Summary

Problem: [Working diagnosis or symptom being referred]

History: [Onset, duration, trajectory, severity, functional impact, pertinent positives and negatives, prior episodes, patient goals/preferences if relevant] (Include dates for onset, flares, and key milestones. If history is limited, state source and limitations.)

Exam: [Pertinent physical exam findings relevant to this referral; include vitals only if they affect urgency or treatment decisions] (Omit if exam was not performed.)

Workup to Date: [Key labs, imaging, procedures with dates and standout findings; prior specialist assessments if any] (Avoid full panel dumps; include only results relevant to the referral question.)

Treatments Tried: [Medication trials with name/dose/duration/response/adverse effects; non-pharmacologic measures; therapies not tried and why]

Impression: [Working diagnosis with certainty level: suspect / likely / confirmed] — [Key differential considerations; conditions to rule out] (Label uncertainty explicitly; do not overstate conclusions.)

Relevant Background

Medications: [Current medications with dose/frequency; flag high-risk meds: anticoagulants, insulin/sulfonylureas, opioids/benzodiazepines, immunosuppressants] (If not fully verified, state "Medication list partially verified" and steps being taken.)

Allergies: [Allergen — reaction type (allergy vs intolerance) — severity] (If none known and verified, state "NKDA." If not verified, state "Allergy status not verified.")

Pertinent History: [Only comorbidities that change specialist decision-making: cardiopulmonary disease, kidney/liver disease, bleeding risk, relevant surgical history with dates] (Omit if not relevant or already covered above.)

Logistics & Response Request

Scheduling: [Patient will call to schedule / Please contact patient at [number]] (Include interpreter or accessibility needs if applicable.)

Requested from Specialist: Please provide your impression, diagnostic/treatment recommendations, any medication changes (note who will implement), follow-up plan, and who is "first call" for this problem going forward.

Send Response To: [EHR routing pool / fax number / secure email] — [Requested timeframe, e.g., within 2 weeks; sooner if urgent findings]

Attachments: [List included items: lab summaries, imaging reports, prior specialist notes, ECG/pathology as applicable] (If external records unavailable, note they were requested.)

Thank you for seeing this patient. Please contact me directly at [phone/secure message] if you have questions or wish to discuss.

Signature: [Clinician name, credentials, direct contact]