COVID@Home Referral Form

Date:    /     /     

Demographic information

Name: 									Gender: 
DOB: 
Home Address: 
Home phone:				Mobile: 
Medicare No: 
Is an interpreter required? (YES/NO)
if yes, please provide details: 

Referral Criteria
Please indicate (with an X):
[   ]     The patient has an acute COVID infection 
(Refer Long COVID patients to the Long COVID clinic)
Type of test: <<Type of test>>		Date of positive test: <<Date of positive test>>
[   ]     Is at moderate risk (Refer high risk patients to rpavirtual)  OR
[   ]     Is low risk with at least one of the following:
[   ]     An additional health issue requiring medical assessment or nursing care for which they would otherwise present to general practice (e.g. suspected UTI, wound care, health anxiety, medication review)
[   ]     Significant parent or carer concern
[   ]     Social risk factor (lives alone with no social supports, limited ability to seek assistance, at risk of violence, abuse or neglect, financial stress, cares for others or patient’s normal carer is unwell)
AND
[   ]    Are not end-of-life or palliated patients (Refer to palliative care) or a resident of an aged care facility
[   ]    There are no significant or unmanaged safety risks for the attending clinicians (Please let us know if there are any potential hazards such as any dogs or cats, concern for domestic violence, hoarding and squalor, patient aggression. Please note the final decision to enter a property will be at the visiting GP’s discretion and they may choose to terminate the visit at any time if there are safety concerns.)

Reason for Referral

Selection	Reasons	Details	
[   ]	BP Check		
[   ]	General Observations		
[   ]	UTI Dipstick		
[   ]	Wound Review		
[   ]	Auscultation of Lungs		
[   ]	Medication Chart Check		
[   ]	Blood Collection		
[   ]	Other (Subject to review)

Clinical information

COVID vaccination doses: 
COVID illness details (include symptoms, hospitalisation):

Current medications:

Allergies 

Relevant past medical history:

Smoking: 
Alcohol: 
Recreational Drugs: (YES/NO)	if yes, please specify: 

I certify that:
This patient is suitable for a home visit and I am unable to perform a home visit.
I have informed the patient of referral to COVID@Home

Referrer details
Name:		Provider No: 
Practice Name:
Practice Address:
Contact Number:
Patient's usual general practitioner (if different from above):