REQUEST FOR MEDICAL OUTPATIENT APPOINTMENT - FAX 03 4215 1383 OR
							     - E-REFER USING REFERRAL NET

GP Referral
		Referral Date: <<Miscellaneous:Date (long)>>

Feedback Requested:  Yes	

Referral to:
Barwon Health Outpatients

Service requested: <<Service Requested:>>
Urgency:  <<Urgency>>	

Referral valid for: 	<<Referral valid for>>		Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
HPI-O: <<Practice:HPI-O>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
HPI-I: <<Doctor:HPI-I>>	
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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>>
Pt IHI:                     <<Patient Demographics:IHI>>
		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: 

 
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>>	
TAC or Workcover? <<TAC or Workcover?>>			

Date patient consented to referral:  <<Miscellaneous:Date (short)>>	
Consent to share information:  <<Consent to share information>>	
Consent to MBS bulk billing clinic if available:  <<Consent to MBS bulk billing clinic >>	

Clinical Information:		<<Patient Demographics:First Name>> <<Patient Demographics:Surname>> DOB:  <<Patient Demographics:DOB>>
HealthPathways provides guidance in patient assessment, management and referral. 
 			<<HealthPathways guidance in Mx Ax referral>>	

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

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Is this a recurrent problem?  <<Is this a recurrent problem?>>
Is this a second referral for the same problem?  <<Is this a 2nd referral for the same problem?>>
Previous relevant consultants or unit invloved in Mx of problem or related problem:
<<Previous consultant/s involved in Mx of problem>>
Recent PHx Medication list review undertaken:  <<Recent PHx Medication list review undertaken?>>

Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>> 

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

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

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

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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>>