PRINCE OF WALES HOSPITAL  
  ADULT OUTPATIENT DEPARTMENT eREFERRAL		

Date of Referral:   <<Miscellaneous:Date (long)>>

Patient Details:
<<Patient Demographics:Full Name>>
<<Patient Demographics:Full Address>>
<<Patient Demographics:Phone (Home)>>
<<Patient Demographics:Phone (Mobile)>>
Date of Birth:  <<Patient Demographics:DOB>>
Gender:   <<Patient Demographics:Sex>>	Medicare No:  <<Patient Demographics:Medicare Number>>
Concession No:  <<Patient Demographics:Pension Number>>
DVA No:    <<Patient Demographics:DVA Number>>
Insurance Fund:  <<Patient Demographics:Health Insurance>>	
Carer Name: <<Carer Name>>	Carer Address: <<Carer Address>>	
Carer Contact: <<Carer Contact>>		
Clinic Referred to:	<<Select recipient from list OR from Address Book>>	
Specialist Referred to if not listed above	<<Addressee:Name>>	
	<<Addressee:Address>>	
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
<<Clinical Details:Allergies>>

Patient Medical History
<<Clinical Details:History List>>

Current Medication List (Includes Regular and PRN)
<<Clinical Details:Medication List>>

Immunisations
<<Clinical Details:Immunisation List>>

Recent investigations
<<Summary:Investigation Results (Selected)>>

Additional Patient Information 		
Has the patient attended Prince of Wales Hospital previously?	<<Has the pt attended Prince of Wales Hospital prev?>>	
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 
<<Doctor:Name>>
<<Practice:Name>>
<<Practice:Address>>
Telephone:  <<Practice:Phone>>
Fax:     <<Practice:Fax>>
Email:  <<Doctor:E-mail>>
Provider Number:  <<Doctor:Provider Number>>	
Patient Name: <<Patient Demographics:Surname>> , <<Patient Demographics:First Name>>  DOB: <<Patient Demographics:DOB>>
Recipient: <<Addressee:Name>>  Date of Report: <<Miscellaneous:Date>>