PRINCE OF WALES HOSPITAL  
  ADULT OUTPATIENT DEPARTMENT eREFERRAL		

Date of Referral:   <TodaysDate>

Patient Details:
<PtName>
<PtAddress>
<PtPhoneH>
<PtPhoneMob>
Date of Birth:  <PtDoB>
Gender:   <PtSex>	Medicare No:  <PtMCNo>
Concession No:  <PtPensionNo>
DVA No:    <PtDVANo>
Insurance Fund:  <PtHealthIns>
IHI: <PtIHI>	
Carer Name:  <Carers Name (If Applicable)>	Carer Address:  <Carer's Address (If applicable)>	
Carer Contact:  <Carer Preferred Contact No.>		
		
Clinic Referred to:	<Select recipient from list OR from Address Book>	
Specialist Referred to if not listed above	<AdrName>	
	<AdrStreet>	
Referral Valid for:	<Referral Valid for:>	
Clinical Urgency: 	<Clinical Urgency>	
Comment if Urgent:	<Comment if urgent>	

Reason for Referral: 	<Reason for Referral>

Clinical Details:
Allergies/Adverse Reactions
<Reactions>

Patient Medical History
<SelectedPMH>

Current Medication List (Includes Regular and PRN)
<CurrentRx>

Immunisations
<Imm>

Recent investigations
<Ix>

Additional Patient Information 		
Has the patient attended Prince of Wales Hospital previously?	<Has the patient attended POWH previously? >	
DVA Transport required? 	<DVA Transport Required?>	
Does the patient require the assistance of an Interpreter?	<Interepreter Required?>	
Please nominate which language/dialect	<Please nominate which language/dialect>	

Referral Source	
Referring Doctor 
<UsrName>
<Practice>
<UsrAddress>
Telehone: <DrPhone>
Fax:     <DrFax>
Email:  <DrEmail>
Provider Number:  <DrProviderNo>	
Patient Name:<PtSurname>, <PtFirstName> DOB: <PtDoB>
Recipient: <AdrName> Date of Report: <TodaysDate>