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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 &amp; 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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