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Second opinion request letter template

Australian documentation guide

A clinical letter body requesting a second opinion. It keeps the person's preferences, existing assessment and unresolved question distinct without judging earlier care.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

Reason for referral

Explain why another opinion is being sought and whose request it is. Include the person’s priorities and the specialty or service requested when established. Keep the tone respectful: seeking another view does not establish that an earlier clinician made an error or that the care plan has changed.

Clinical summary

Describe the relevant history, assessments and evidence available. Attribute an earlier diagnosis or opinion to its source and retain its degree of certainty. Include important differences between the person’s account and the records without deciding which is correct on their behalf.

Current management

Summarise the care actually underway and options already discussed. Separate a recommendation, a person’s decision and an action completed. Do not imply that requesting another opinion pauses treatment, cancels a booking or authorises a different plan unless that was explicitly documented.

Specific question

Make the question easy to answer. It may concern an existing assessment, options already discussed or an uncertainty the referring clinician identified. Use the question actually recorded rather than generating new diagnostic or treatment possibilities. This required field stays [not stated] if the request has not been clarified.

Current medications

Give the available list with its source and currency. Preserve established names and directions, and show missing details. A second-opinion request should not turn an incomplete medicine history into a complete reconciled list or introduce a medicine change.

Allergies and adverse reactions

Include the substance and reaction where known, identifying the source and any uncertainty. Distinguish a documented negative history from a history that was not obtained. Required information that is absent stays [not stated] for review.

Common omissions

Look for the person’s actual question, access or communication preferences, earlier reports and who continues care while the opinion is arranged. Do not describe an attachment as enclosed or an appointment as booked until that is established.

Review before sending

Check that the letter gives a fair account of the earlier opinion and makes the new request clear. Confirm consent, recipient, identifiers, relevant enclosures and the sending clinician’s review. Verify any applicable referral requirements separately; the template does not establish eligibility, validity or a receiving clinician’s acceptance.

Worked examples

A person's request for another opinion before a decision

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: The person requests a second orthopaedic opinion before deciding whether to proceed with the knee procedure previously discussed. They consent to relevant records being shared.
CLINICAL SUMMARY: The existing orthopaedic correspondence records right knee osteoarthritis. The person describes pain with longer walks and says their priority is understanding how the options relate to returning to walking with friends. No new examination or diagnosis is recorded today.
CURRENT MANAGEMENT: The earlier correspondence documents a course of physiotherapy and a discussion of a possible procedure. The person reports continuing the agreed exercises. No procedure has been booked in the available record.
SPECIFIC QUESTION: The referral asks for an opinion on the previously discussed options, their expected benefits and limitations, and how they relate to the person's stated goals. No change to the existing plan is recorded while this opinion is requested.
CURRENT MEDICATIONS: The person reports occasional paracetamol use; dose and frequency are not stated in this extract. No complete reconciled list is available.
ALLERGIES & ADVERSE REACTIONS: The current record states no known medicine allergy, last reviewed on 1 October. The letter identifies the record as the source.

A request that still needs a specific question

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

REASON FOR REFERRAL: The person has asked to discuss another opinion. The intended specialty and consent to send this draft are not stated.
CLINICAL SUMMARY: Previous correspondence is mentioned but its assessment is not included in this extract.
CURRENT MANAGEMENT: [not stated]
SPECIFIC QUESTION: [not stated]
CURRENT MEDICATIONS: [not stated]
ALLERGIES & ADVERSE REACTIONS: [not stated]

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.