Integrated Team Care Referral

Referral to:
Karadi Aboriginal Corporation
PO BOX 523
Glenorchy TAS 7011
Phone: (03) 62723511
Fax: (03) 62723588

Thank you for seeing:

Patient Name: <PtFullName>	Date of Birth: <PtDoB>	

Address: <PtStreet>, <PtCity>, <PtState>, <PtPostcode>	

Mobile: <PtPhoneMob>	Home: <PtPhoneH>	Email: <PtEmail>	

My patient fulfils this criteria (please tick)
	Identifies as Aboriginal/Torres Strait Islander 	

	Have Aboriginal and/or Torres Strait Islander ancestry 	

	Is known as such in the community in which they live or formally lived	

Has one or more of the following chronic diseases (please tick all that apply)
	Cancer	

	Cardiovascular	

	Diabetes	

	Renal Disease	

	Respiratory Disease	

	Asthma	

	Other (i.e. Mental Health, Obesity, Musculoskeletal) Please List: 	

	Client has given verbal or written consent to participate in this program	

	Client GP Management Plan or Team Care Arrangements Plan is attached	

Karadi may at times offer 715 Aboriginal Health Checks. Would you like your client to have their check completed by our team and forwarded to you for follow up?  Yes/No	

Any other relevant information: 

Referring GP: <DrName>	Provider No: <DrProviderNo>	

Practice Name: <Practice>		

Address: <Practice>, <DrStreet>, <DrCity>, <DrState>, <DrPostcode>	

Phone: <UsrPhone>	Fax: <UsrFax>	Date: <TodaysDate>