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.Mailing Address	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 Status
Compensable: 
DVA number: Patient Demographics.DVA Number
Interpreter required: Interpreter Required
If yes, language: Language	
GP details		
Name: Treating Doctor.Name	Contact Number: Treating Doctor.Phone	
Substitute decision maker/person responsible 	
Name: Subtitute Decision
Contact number: Subtitute Decision	Relationship: Subtitute Decision
Patient consent to referral: Patient Consent	
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 Ass.	
*Neurorehabilitation Clinic
Neurorehabilitation	
*Musculoskeletal Rehabilitation
Musculoskeletal Reha	
General Rehabilitation (includes chronic stroke)
General Rehab.	
Spasticity Clinic
Spasticity Clinic	
Fragility Fracture Service
Fragility Fracture 	
Youth Rehabilitation Transition Clinic
Youth Rehabilitation	
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	
Memory Clinic
Memory Clinic	
Falls Clinic
Falls Clinic	
Nursing Home Visits Service
Nursing Home Visits 	
Southern Fleurieu Aged Care Clinic
Southern Fleurieu AC	

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.Medications - Current PRN
Clinical Details.Allergies

Clinical Details.Result List (Selected)

Clinical Details.Social History
Clinical Details.Todays Notes

Referrer's details	
Name: Miscellaneous.Current User
Designation: Practice.Name
Signature

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