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:Sex>>	
Date of Referral:  <<Miscellaneous:Date (short)>>	Referring Health Agency: <<Practice:Name>>	
Client Aware of Referral: <<Client aware of referral >>	Form Completed By: <<Miscellaneous:Current User>>	
Client Consent Given: <<Client Consent for Referral >>	Position: <<Role in care >>	
Guardianship of the Minister: <<Guardianship of the Minister >>	Tel: <<Practice:Phone>>	Fax: <<Practice:Fax>>	
REFERRING HOSPITAL (If referral is from Hospital please complete the following section)	
Patient Requires:  <<Patient requires services >>	
Admission Date: <<Hospital Admission Date >>	Hospital Ward: <<Hospital Ward >>	
Discharge Date: <<Hospital Discharge Date >>	Hospital Medical Record: <<Hospital Medical Record Number >>	
Follow Up GP/ Outpatient Appointment Date: <<Post Discharge Date >>	Required Service Date: <<Required Service Date Start >>	
CLIENT INFORMATION                                                         INDIVIDUAL HEALTH IDENTIFIER: <<Patient Demographics:IHI>>	
Title: <<Patient Demographics:Title>>	Marital Status: <<Patient Demographics:Marital Status>>	
Residential Address: <<Patient Demographics:Full Address>>	
Postal Address: <<Patient Demographics:Full Address Postal>>	
Home Tel: <<Patient Demographics:Phone (Home)>>	Work Tel: <<Patient Demographics:Phone (Work)>>	Mobile Tel: <<Patient Demographics:Phone (Mobile)>>	
Country of Birth: <<Patient Demographics:Country of Birth>>	Language Spoken at Home: <<Patient Demographics:Language Spoken>>	
Private Health Insurance:    <<Patient Demographics:Health Insurance>>           Extras Cover: <<Health Insurance Extras Cover >>
Ambulance Cover: <<Ambulance Cover >>	
Regular GP: <<Patient Demographics:Referral Doctor>>
GP/ Medical Clinic: <<Practice:Name>>	

Pre-Existing GPMP: <<Patient has a GPMP >>	

	Allergies /Infectious Conditions: <<Clinical Details:Allergies/Adverse Reactions>>	
Pre- Existing TCA: <<Patient has a TCA >>	

Pre-Existing Service Providers: <<Pre-existing Service Providers >>	

	Known Hazards for Home Visits: <<Known hazards for home visits >>	
Medicare Card#:    <<Patient Demographics:Medicare Number>>               Individual Reference #:     <<Individual Reference Number >>                                           Expiry:  <<Patient Demographics:Medicare Expiry Date>>	
Concession Card #: <<Patient Demographics:Pension Number>> <<Patient Demographics:DVA Number>>	Type:                         Expiry:	
National Disability Insurance Scheme#: <<NDIS Number >>	Compensable: <<NDIS Compensable >>	
Client Lives: <<Client lives >>	Client Has Carer: <<Client has Carer >>	
Advance Care Directive: <<Client has Advance Care Directive >>	Client Lives with Carer: <<Client lives with Carer >>	
EMERGENCY CONTACT/ GUARDIAN/ CARER/ SUBSTITUTE DECISION MAKER	
Name: <<Emergency Contact Name >>	Relationship: <<Emergency Contact Relationship >>	
Address: <<Emergency Contact Address>>	
Home Tel: <<Emergency Contact Home Tel>>	Work Tel:<<Emergency Contact Work Tel>>	Mobile Tel: <<Emergency Contact Mobile>>	
CLINICAL DETAILS	
Medical History (Primary and Secondary Diagnosis / Current recent Hospital admissions details) 
<<Clinical Details:History List>>	
Presenting Problem: 
<<Summary:Progress Note (Current)>>	
Medication List:
<<Clinical Details:Medication List>>	
Management/ Care Requested (Reason for referral request for Service type and care needed)
 <<Reason for Referral >>
<<Service details requested>>	
Fax Completed form to: 08 8115 5734
Telephone: 1800 003 307  or 
Port Pirie Regional Health Service Country Connect Intake 	Office Use Only

PP