REQUEST FOR COMMUNITY HEALTH & REHABILITATION SERVICES - FAX 03 4215 7795 OR
								E-REFER USING REFERRAL NET	   
GP Referral
		Referral Date: <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to:
Barwon Health Community Health & Rehabilitation Programs
Phone: 1300 715673
Fax:  03 4215 7795

Select up to 5 services <<Select up to 5 services>>
Service request 1: <<Service request 1>>
Service request 2:  <<Service request 2>>
Service request 3:  <<Service request 3>>
Service request 4:  <<Service request 4>>
Service request 5:   <<Service request 5>>
Urgency:  <<Urgency>>
		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>

Consumer details:
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>

ATSI:  <<Patient Demographics:ATSI>> 		Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>

Alternative Contact: 
<<Alternative Contact (Name/Ph/Relationship)>>

Interpreter required: <<Does the patient require an interpreter?>>		DVA Number: <<Patient Demographics:DVA Number>>	
Preferred language is: <<If interpreter needed, which language>>		Insurance: <<Patient Demographics:Health Insurance>>	
Pension Card Number: <<Patient Demographics:Pension Number>>		Medicare Number: <<Patient Demographics:Medicare Number>>	

Date patient consented to referral:  <<Miscellaneous:Date>>	
Consent to share information:  <<Consent to share information>>	
Consent to MBS bulk billing clinic:  <<Consent to MBS bulk billing clinic>>	

Clinical Information:		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>> 

Please consider Telehealth for this patient:  <<Please consider Telehealth for this patient>>	

Reason for patient referral: 
<<Reason for Referral>>

Desired Patient Outcomes of Care:
<<Desired patient outcomes of care>>
                                                                    
Other Notes (Current services):  <<Other notes (eg Current services)>>	

Warnings: <<Clinical Details:Warnings>>
Allergies: <<Clinical Details:Allergies>> 
Social History: <<Clinical Details:Social History>>  <<Clinical Details:Smoking>> 
If smoker, has smoking cessation been discussed?:  <<If yes to smoking, cessation program discussed?>>	

Current Medication:
<<Clinical Details:Medication List>>	

Past Medical History: 
<<Clinical Details:History List>>	

Progress Notes: 
<<Summary:Progress Notes (Selected)>>	
 
Investigation Results:
<<Summary:Investigation Results (Selected)>>	

 

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>