Sex: ¨ M ¨ F 	Marital Status:  ¨Married/Defacto  ¨ Never Married  ¨ Widowed  ¨ Divorced  ¨ Separated  ¨ Not Known

Permanent Address: <PtAddress>
Postcode:<PtPostcode>	
Phone: <PtPhoneH>	

Current Address:							Postcode:		Phone:	

Age:	<PtAge>	Country of Birth:		Year of Immigration:		Language used at Home: 	

Interpreter Required?	Religion:				Occupation/Former Occupation: <PtOccupation>	

Indigenous Status:	Service Unit on Admission		Source of Referral

¨Torres Strait Islander 	¨Aboriginal	¨Rehabilitation	¨Day Only	¨Community	¨Outpatients
¨Neither A or TSI	¨Both A & TSI	¨Palliative Care	¨Day Only	¨Hospital in AHS	¨Other Hospital
Health Insurance	¨Pain Clinic	¨CPCT		¨Nursing Home	¨Med Practitioner
¨Medicare	¨Private	¨Third Party	¨CRAGS ________________		¨Self		¨Family
¨Veterans Affairs	¨Workers Compensation	¨Other 	__________________	¨Friend		¨Neighbour
¨Ineligible	¨Other	If applicable: Date of Admission &	¨Hostel		¨Other
Name of Fund:_________________________	Discharge from Hospital within last	Specify the source name & referring doctor:
Membership No:_______________________	28 days:_______________________

Is the patient on a Pension? ¨   Y  ¨  N  Social Security No: _______________________

Repat. Pension: ¨  Y  ¨  N  R.P. No.___________________ Colour: G / W Appr:  Y/N	MEDICARE NUMBER (10 Digits)

Pension Type: 	¨ Invalid	¨ Aged	¨ Carers	¨ Superannuation

¨ Overseas	¨ Special Benefits	¨ Other __________________________

Next of Kin / Person (s) for Notification:
(1)	Name:___________________________________________	Relationship:_________________________	Home:_________________

	Address:________________________________________________________________________________	Work:__________________

(2)	Name:___________________________________________	Relationship:_________________________	Home:_________________

	Address:_________________________________________	Relationship:_________________________	Work:__________________

Carer’s Details: _________________________________________________________________________________________________________

Local Medical Officer:  Name:	<DrName>				Address: <DrStreet>
Phone: <DrPhone>					Facsimile: <DrFax>

Is LMO aware of Referral:  ¨  Y  ¨  N		Agreed to Receive Discharge Summary by Fax:  ¨  Y  ¨  N

Attending Medical officer / Case Manager:

DIAGNOSIS:
Major Problems on Referral / Admission

							Services Requested:
Is the patient aware of referral ?  ¨ Yes  ¨  No

Name:						Designation:				Date:

Contact Phone:							Signature: