STATEWIDE STANDARD OUTPATIENT REFERRAL FORM
REQUEST FOR OUTPATIENT APPOINTMENT
Referral to: Consultant Hospital: Preferred Hospital
Urgency: Urgency Clinic: OPD Clinic Required
Patient Details
Name: Patient Demographics.Full Name
Address: Patient Demographics.Full Address
DOB: Patient Demographics.DOB
Gender: Patient Demographics.Gender
ATSI Status:
Phone: Patient Demographics.Phone (Home) Patient Demographics.Phone (Mobile)
DVA/Medicare: Patient Demographics.DVA Number Patient Demographics.Medicare Number
Medicare Exp Patient Demographics.Medicare Expiry Date
Compensable Compensable Compensation number
Interpreter Required: Interpreter required If Yes, language: If Yes, Language
Reason for referral:
Patient carer details: Carer details
Other considerations
& patient requirements
Other considerations
Reason for Referral:
Reason for referral
Current/Past History: Clinical Details.Problem List (Current) With Comments, Onset Year
Current Medications:
Clinical Details.Medication List
Allergies:
Clinical Details.Allergies With Comments
Relevant Social History: Clinical Details.Social History
Other Relevant Health Professionals :
Other relevant healt
Date of referral : <<Miscellaneous:Date>> Alternative hospital(s) the patient is willing to attend: <<Would the patient consider an alternative site? >>
General Practitioner Details
Treating Doctor.Full Details
Investigations: <<Summary:Investigation Results (Selected)>>
Referral Duration: Referral Duration
Information contained in this referral form may be private and also may be subject of legal professional privilege or public interest. If you are not the intended recipient, any use, disclosure or copying of this document is unauthorised under the Health Care Act 2008 and may attract a fine of up to $10,000. If you have received this document in error, please contact the referrer.