Community Health Service
REFERRAL FORM	UR / MRN:
Surname: Patient Demographics.Surname
Given Names: Patient Demographics.First Name
Preferred Name: 
DOB:  Patient Demographics.DOB                     Gender: Patient Demographics.Gender	
Date of Referral: Miscellaneous.Date	Referring Health Agency: Practice.Name	
Client Aware of Referral: Client Consent	Form Completed By: Treating Doctor.Name	
Client Consent Given: Client Consent 	Position: Role in care 	
Guardianship of the Minister: Guardianship 	Tel:Treating Doctor.Phone	Fax:Treating Doctor.Fax	
REFERRING HOSPITAL (If referral is from Hospital please complete the following section)	
Patient Requires: In Hospital Referral	
Admission Date:Admission Date 	Hospital Ward: Hospital Ward 	
Discharge Date: Discharge Date 	Hospital Medical Record: Hospital Record	
Follow Up GP/ Outpatient Appointment Date: Appointment Date 	Required Service Date: Service date	
CLIENT INFORMATION                                                               INDIVIDUAL HEALTH IDENTIFIER: Patient Demographics.IHI Number	
Title: Patient Demographics.Title	Marital Status: Patient Demographics.Marital Status	
Residential Address: Patient Demographics.Address	
Postal Address: Patient Demographics.Mailing Address	
Home Tel: Patient Demographics.Phone (Home)	Work Tel:Patient Demographics.Phone (Work)	Mobile Tel: Patient Demographics.Phone (Mobile)	
Aboriginal/ Torres Satrit Islander: ATSI Status 	Interpreter required: Interpreter Required	
Country of Birth: Country of Birth 	Language Spoken at Home:Language 	
Private Health Insurance:     Patient Demographics.Health Fund Name     Patient Demographics.Health Fund Member Number     Extras Cover: Health Fund details 
Ambulance Cover: Ambulance Cover	
Regular GP: Regular GP 
GP/ Medical Clinic: Regular GP Practice 	Allergies /Infectious Conditions: Clinical Details.Allergies	
Pre-Existing GPMP: GPMP in place 		
Pre- Existing TCA: TCA in place 	Known Hazards for Home Visits: Home Hazards	
Pre-Existing Service Providers:		
Medicare Card#:    Patient Demographics.Medicare Number                 Individual Reference #:  Patient Demographics.Reference Number                                              Expiry: Patient Demographics.Medicare Expiry Date	
Concession Card #:Patient Demographics.Pension Number
Patient Demographics.DVA Number	Type:     Card Type            Expiry: Patient Demographics.DVA Expiry Date	
National Disability Insurance Scheme#: NDIS Number 	Compensable: NDIS Compensable	
Client Lives:Client Lives 	Client Has Carer:Client has Carer 	
Advance Care Directive: Care Directive 	Client Lives with Carer:Client lives carer	
EMERGENCY CONTACT/ GUARDIAN/ CARER/ SUBSTITUTE DECISION MAKER	
Name:Patient Demographics.Emergency ontact Name	Relationship:Patient Demographics.NOK Relationship	
Address: NOK Address	
Home Tel: Patient Demographics.NOK Home Phone	Work Tel:Patient Demographics.NOK Work Phone	Mobile Tel: Patient Demographics.NOK Mobile Phone	
CLINICAL DETAILS	
Medical History (Primary and Secondary Diagnosis / Current recent Hospital admissions details) 
Clinical Details.Problem List (Current)	
Presenting Problem: 
Clinical Details.Selected Most Recent Measures	
Medication List:
Clinical Details.Medications - Current PRN	
Management/ Care Requested (Reason for referral request for Service type and care needed)
 Care Service 
Service details 	
Fax Completed form to: 1800 771 211
Telephone: 1800 003 307
Central Referral Unit  	Office Use Only

CRU