REQUEST FOR BARWON HEALTH CANCER SERVICES			FAX 03 4215 2743 (Public)
										FAX 03 4215 2836 (Private)	
GP Referral
		Referral Date: <TodaysDate>

Feedback Requested:  Yes	

Referral to:
Andrew Love Cancer Centre
Telephone: 03 4215 2700; 
Fax: Public 03 4215 2743, Private 03 4215 2836
<Pts have a choice of public or private clinics (no OOP)>
Public or Private referral: <Are you referring this patient as public or private?>

Public service requested: <If public oncology select service required:>	

Private service requested: 
<If Private Medical Oncology - requested consultant> 

<If Private Radiation Oncology - requested consultant> 

<If Private Haematology - requested consultant>

Urgency: <Urgency>		Referring General Practitioner:
<DrName> 
<Practice>
<UsrAddress>
HPIO: <PracHPIO>
Phone: <UsrPhone>   Fax: <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>
HPII: <DrHPII>	

Consumer details:
Name:	<PtFirstName> <PtSurname>
Date of Birth:	<PtDoB>
Age:                        <PtAge>
Preferred Name/s:	<PtPrefName>
Sex:	<PtSex>
Title:	<PtTitle>
IHI: <PtIHI>
		Contact Address:	<PtName>
	<PtStreet>
	<PtCity>  <PtState>    <PtPostcode>
Phone:	<PtPhoneH>
Work:	<PtPhoneWk>
Mobile:	<PtPhoneMob>
Email:	<PtEmail>

Alternative Contact: 

Interpreter required: <Does the patient require an interpreter?>		DVA Number: <PtDVANo>	
Preferred language is: <If interpreter needed, which language>		Insurance: <PtHealthIns>	
Pension Card Number: <PtPensionNo>		Medicare Number: <PtMCNo>	
	
How long is the referral for: <How long is the referral for?>	

HealthPathways provides guidance in patient assessment, management and referral.
<HealthPathways provides assistance in Ax Mx referral of pts>	

Reason for patient referral: 
<Reason for Referral (incl Dx or prov Dx if known)>
 --------------------------------------------------------------------------------------------------------------
Is tissue Dx known? <Is tissue Dx known?>
If No, please organise tissue Dx, if feasible: <If No, please organise tissue Dx if feasible>
What has the patient been told? <What has the patient been told?>
Please ensure PHx Medication list review is undertaken:  <Recent PHx Medication list review undertaken?>
Specialist/s involved:  <Specialist/s involved>
Other relevant information: <Other relevant information>
Warnings: <Comment>
Allergies: <Reactions> 

Current Medication: 
<CurrentRx>
GP Management Plan: <GP Mgt plan>
Team Care Arrangement: <Does Pt have a Team Care Arrangement>

Past Medical History: 
<PMHAll>  
Family History:
<Is there a FHx of cancer?>
<FamilyHx>
Social History: 
<SocialHx> 
Progress Notes: 
<Visits>
Investigation Results:
<Ix>

Did the HealthPathways website assist you in the assesment, management or referral of your patient? <Did HealthPathways assist in Ax Mx referral of pt?>	

Patient: <PtSurname>, <PtFirstName>  DOB: <PtDoB>