STATEWIDE STANDARD OUTPATIENT REFERRAL FORM
 REQUEST FOR OUTPATIENT APPOINTMENT	
				
Referral to:	<Name of prefered Consultant>	Hospital:	<Preferred Hospital>	
Urgency:	<Urgency>	Clinic:	<OPD Clinic required>	

Patient Details	
Name:	<PtName>	
Address:	<PtStreet> <PtCity> <PtState> <PtPostcode>	
DOB:	<PtDoB>	
Gender:	<PtSex>	
ATSI Status:	<ATSI Status>	
Phone:	<PtPhoneH>	<PtPhoneMob>	
DVA/Medicare:	<PtDVANo>	<PtMCNo>	
Medicare Exp		<PtMCExpiry>	
Compensable	<Compensable?>	<Compensation number>	
Interpreter Required:	<Interpreter required>	If Yes, language:	<If Yes, language>	
Patient carer details:	<Carer details (If required)>	
Other considerations
& patient requirements	<Other considerations/patient requirements>	

Reason for referral:
<Reason for referral >

Current/Past History:
<SelectedPMH>

Current Medications:
<SelectedRx>

Allergies:
<Reactions>

Relevant Social History:
<SocialHx>

Other Relevant Health Professionals :
<Other relevant health professionals involved?>

General Practitioner Details	
<DrDetails>	
Date of referral: <TodaysDate> 

Alternative hospital(s) the patient is willing to attend:
<Would the patient consider an alternative site?>

Referral Duration:	<Referral Duration>	

Investigations:
<Ix>

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.