eReferral

* Required

Referrer Details

Program Selection

Date of Referral

Referral Source

Date of First Contact

Patient Details

Gender

Title

First Name *

Last Name *

Email Address *

Surname

First Name

Date of Birth

Visit Address

Suburb

Poscode

Phone

Mobile

Interpreter Required? Yes

If so which language?

Further Patient Information (if known)

Next of Kin

Relationship

Phone

Mobile

Visit Request Date

Check all that apply

Pension Card

Health Care Card

DVA Entitlement

Private Insurance

Workers Compensation

Accident Cover

Case Manager

Medicare Number

DVA File Number

DVA Card Colour

Fund Name

Claim Number

Phone

Insurer

Referral Source Information

Referring source name

Referral source contact number

Hospital UR

Ward

Admit date

Discharge date

GP Name (if not referral source)

Provider Number

GP Phone Number

Primary Diagnosis

Secondary Diagnosis

Relevant past history

Allergy/ Alert/ ADR

Required Services from HSS

Referral reason

Specific management request

Other additional information about this patient: (hazards to nurses or others attending the home)

Medication Authorisation Organised? (Signed medication authority required for any drug administration) Yes

Anaphylaxis Yes

Name of person completing this form

Contact Number