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<pre>
Referrer s signature:
Metropolitan Referral Unit
Continence Device Change Hospital Avoidance
Referral Fax 1300 546 104
Referral source ? RACF ? GP
Date of referral: / / Time: / /
Requested Service Commencement date: / /
Referring Facility:
Room/ Section:
Aged Care Facility:
Phone number for RN in RACF:
USUAL LIVING:
Alone Spouse/Partner
Disability Housing Other:
NOK: (Relationship): GP/Practice:
NOK Phone (s): GP Phone:
INDIGENOUS STATUS: Aboriginal Torres Strait Islander Both Neither Unknown
COUNTRY OF BIRTH: Australia Other (specify):
Interpreter required? specify
KNOWN RISKS TO COMMUNITY STAFF VISITING HOME: (Environment/ Aggression/ COVID RISKS)
PRIMARY DIAGNOSIS: _____
PMH & Secondary Conditions:
ALLERGIES: MRO: MRSA VRE Other MRO __________
MANAGEMENT PLAN / CARE REQUESTED: (please attach with this form any additional information to assist community care delivery)
IDC SPC
Date last changed: / /
Changed by:
Size of device:
Brand of device:
Comments :
Do you have a catheter or drainage bag in stock?
Please complete form and FAX to 1300 546 104 or Phone 1300 110 600. Please ensure you confirm we have received your referral for assessment.
Print Name:
Role/Designation: Contact number:
PATIENT INFO Sticker/MR10/UR No:
Surname: First name:
Address:
Suburb:
P/Code:
? Male ? Female DOB: / /
Telephone:
Mobile:
Address where care to be provided (if not usual address)
Address:
Suburb:
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