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STATEWIDE STANDARD OUTPATIENT REFERRAL FORM REQUEST FOR OUTPATIENT APPOINTMENT
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Referral to: |
Consultant
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Hospital: |
Preferred Hospital
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Urgency: |
Urgency
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Clinic: |
OPD Clinic Required
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Name: |
Patient Demographics.Full Name
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Address: |
Patient Demographics.Full Address
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DOB: |
Patient Demographics.DOB
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Gender: |
Patient Demographics.Gender
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ATSI Status: |
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Phone: |
Patient Demographics.Phone (Home)
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Patient Demographics.Phone (Mobile)
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DVA/Medicare: |
Patient Demographics.DVA Number
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Patient Demographics.Medicare Number
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Medicare Exp |
Patient Demographics.Medicare Expiry Date
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Compensable |
Compensable
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Compensation number
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Interpreter Required: |
Interpreter required
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If Yes, language: |
If Yes, Language
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Reason for referral:Patient carer details: |
Carer details
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Other considerations & patient requirements
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Other considerations
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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
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Investigations:
<<Summary:Investigation Results (Selected)>>Referral Duration: |
Referral Duration
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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.