Outpatient Medical Rehabilitation and Aged Care Clinics Referral Form 
Private patients are Medicare bulk billed for outpatient clinic services						Please Fax To:
					(08) 8404 2263

Patient details	Date of referral: 	
Surname: <<Patient Demographics:Surname>>
Given Name(s): <<Patient Demographics:First Name>>
Address: <<Patient Demographics:Full Address>>

Postal address (if different from above):
<<Patient Demographics:Full Address Postal>>	DOB: <<Patient Demographics:DOB>>                                Gender: <<Patient Demographics:Gender>>
Telephone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Medicare number: <<Patient Demographics:Medicare Number>>
MRN:
ATSI Status: <<Patient Demographics:ATSI>>
Compensable:
DVA number: <<Patient Demographics:DVA Number>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
If yes, language: <<If interpreter required: what language?>>	
GP details		
Name: <<Doctor:Name>>	Contact Number: <<Doctor:Phone>>	
Substitute decison maker/person responsible/next of kin	
Name: <<Substitute decision maker: Name >>
Contact number: <<Substitute decision maker: Phone>>	Relationship: <<Substitute decision maker: Relationship>>
Patient consent to referral: <<Patient consent to referral>>	
Please only select the preferred doctor below
4th Generation Outpatient medical only assessment clinics - indicate preferred doctor	
PLEASE NOTE - ALL INITIAL CONSULTS REQUIRE AN IN-CLINIC APPOINTMENT.
TELEHEALTH SERVICES ARE AVAILABLE FOR SUITABLE CLIENTS FOR REVIEW APPOINTMENTS.
SEE *SERVICES BELOW	
REHABILITATION CLINICS
*Driving Fitness Assessment
<<Driving Fitness Assessment>>	
*Neurorehabilitation Clinic
<<Neurorehabilitation Clinic>>	
*Musculoskeletal Rehabilitation
<<Musculoskeletal Rehabilitation>>	
General Rehabilitation (includes chronic stroke)
<<General Rehabilitation (includes chronic stroke)>>	
Spasticity Clinic
<<Spasticity Clinic>>	
Fragility Fracture Service
<<Fragility Fracture Service>>	
Youth Rehabilitation Transition Clinic
<<Youth Rehabilitation Transition Clinic>>	
Frailty Clinic
<<Frailty Clinic>>
	
4th Generation Outpatient medical only assessment clinics - indicate preferred doctor	
PLEASE NOTE - ALL INITIAL CONSULTS REQUIRE AN IN-CLINIC APPOINTMENT.
TELEHEALTH SERVICES ARE AVAILABLE FOR SUITABLE CLIENTS FOR REVIEW APPOINTMENTS.
SEE *SERVICES BELOW	
AGED CARE CLINICS
Aged Care Clinic (including memory assessment)
<<Aged Care Clinic (including memory assessment)>>	
Memory Clinic
<<Memory Clinic>>	
Falls Clinic
<<Falls Clinic>>	
Nursing Home Visits Service
<<Nursing Home Visits Service>>	
Southern Fleurieu Aged Care Clinic
<<Southern Fleurieu Aged Care Clinic>>	

Referral information	
Reason for referral: <<Reason for Referral>>	
Please provide details including PMHx. current medications and allergies, relevant investigations results and social issues:

<<Clinical Details:History List>>
<<Clinical Details:Medication List>>
<<Clinical Details:Allergies/Adverse Reactions>>

<<Summary:Investigation Results (Selected)>>
<<Clinical Details:Social History>>

Referrer's details	
Name: <<Doctor:Name>>
Designation: <<Practice/Location:Name>>
Signature:

Provider no: <<Doctor:Provider Number>>    	Date: <<Miscellaneous:Date>>
Referral period: <<Referral Period>>
Referring unit:
Referring Consultant:
Tel: <<Doctor:Phone>>
Fax: <<Doctor:Fax>> 	
 Please phone (08) 8404 2269 if any queries regarding referrals