REQUEST FOR BARWON HEALTH CANCER SERVICES	FAX 03 4215 2743 (Public)
									FAX 03 4215 2836 (Private)

GP Referral
		Referral Date: Miscellaneous.Date

Feedback Requested:  Yes	

Referral to:
Andrew Love Cancer Centre
Phone: 03 4215 2700 ; 
Fax: Public 03 4215 2743, Private 03 4215 2836
Pts have a choice 
Public or Private referral: Are you referring pt 

Public service requested: If public oncology 

Private service requested:
If Private Med Onc

If Private Rad Onc

If Private Haem 

Urgency: Urgency
		Referring General Practitioner:
Treating Doctor.Name
Address: Practice.Address
HPI-O:
Ph: Practice.Phone
Fax: Practice.Fax
Provider No.: Treating Doctor.Provider Number 
HPI-I:

Consumer details:
Name: Patient Demographics.Full Name
Date of Birth:.Patient Demographics.DOB
Age:.Patient Demographics.Age
Sex: Patient Demographics.Gender
Title: Patient Demographics.Title
Pt IHI: Patient Demographics.IHI Number
		Contact Address:
Patient Demographics.Full Name
Patient Demographics.Full Address
Tel (H): Patient Demographics.Phone (Home)
Tel (M): Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Alternative Contact: 

Interpreter required: Interpreter required		DVA Number: Patient Demographics.DVA Number	
Preferred language is: Interpreter language		Medicare Number: Patient Demographics.Medicare Number	
Pension Card Number: Patient Demographics.Pension Number		Private Health Insurance 	

How long is the referral for: Referral length	

HealthPathways provides guidance in patient assessment, management and referral.
HealthPathways

CLINICAL INFORMATION:

Reason for patient referral: 
Referral reason	
Is tissue dx known? Is tissue dx known?
If No, please organise tissue dx if feasible: Organise tissue dx	
What has the patient been told? What has pt been tol	
Recent PHx Medication list review  undertaken: PHx medication revie	
Specialist/s involved: Specialist/s involve
Other relevant information: Comments	
Warnings: Clinical Details.Warnings	
Allergies: Clinical Details.Allergies	

Current Medication:
Clinical Details.Medications Current Regular	
GP Management Plan: GP Management Plan?	
Team Care Arrangement: Team Care Arrangemen	
Social History:
Clinical Details.Social History	
Family History:Clinical Details.Family History	
Past Medical History: 
Clinical Details.Problem List (Resolved) With Comments	
Current Medical History:
Clinical Details.Problem List (Current) With Comments	

Investigation Results:
Clinical Details.Result List (Selected)	

Did the HealthPathways website assist you in the assessment, management or referral of your patient?: HealthPathways