Please forward all investigation results which led to the referral.
Referral must include:
• Patient demographics including full name, date of birth, contact details, postal address or contact address (if not the same as usual residence)
• Date of referral
• Referring practitioner's full name, address and contact details
• Referring practitioner's provider number and signature
• Detailed reason for referral (including the problem to be assessed, degree of loss of function, pain experienced, ect)
• Relevant information about patient's condition such as previous medical/ surgical treatment (include systemic and topical medications prescribed for the condition) and any associated medical conditions which may affect the condition or its treatment (e.g. Diabetes)
• Current medications and doses, prescribed and over the counter (Note any recent changes in drug therapy)
• Allergies (drug/ topical preparation)
• Aboriginal, Torres Strait Islander status
Desirable Referral Information:
• Relevant psychological and social issues impacted by condition
• Smoking and alcohol history
• South Sea Islander status
• Medicare Number
• Interpreter requirements
• Patient status (DVA, Work cover, Motor Vehicle Insurance, Medicare Ineligible)
Please forward all investigation results which led to the referral