myagedcare

Fax: 1800 728 174 	1800 200 422                     Mon-Fri 8am - 8pm
                                                   Sat 10am - 2pm
Page 1 of 2	

Recipient details			
Title		 <PtTitle>	
First name		 <PtFirstName>	
Last name		 <PtSurname>	
Date of birth		 <PtDoB>	
Gender		 <PtSex>	
Marital Status		 <PtMaritalSt>	
Indigenous/Cultural status		 <PtEthnicity>	
Language spoken at home/ interpreter		 <Language spoken at home>  <Interpreter ?>	
Medicare number		 <PtMCNo>	
IRN			
DVA number		 <PtDVANo>	
			
Support Person			
Support person-first name		 <Support Person - First Name>	
Support person-last name		 <Support Person - Second Name>	
Phone No		 <Support Person - Contact number>	
Relationship		 <Support Person - Relationship>	
			
Contact details			
Address line 1		 <PtStreet>	
Address line 2		 	
Suburb/Town		 <PtCity>	
State		 Tasmania	
Postcode		  <PtPostcode>	
Can the client be assessed over the phone?		 <Can the Client be assessed over the phone>	
Phone Number		 (h) <PtPhoneH>  (m) <PtPhoneMob>	
Call back day		 <Cllient availability call back days -list all>	
Call back time		 <Preferred Client Call Back time>	
			
Date of Referral		 <TodaysDate>	

                     myagedcare

Fax: 1800 728 174 	1800 200 422                     Mon-Fri 8am - 8pm
                                                   Sat 10am - 2pm
Page 2 of 2	

Referrer details			
Role at Health Facility		  <Your Role>	
Name		  <UsrName>	
		 	
Practice Name		  <Practice>	
Address		  <UsrAddress>	
State		  Tasmania	
Phone		  <UsrPhone>	
Fax		  <UsrFax>	
Email		 <PracEmail>	
			
Relationship to Consumer		  See Job Title	
Referral Reason		  <Referral Reason>	
			
Do you have consent from the patient to make this referral?		 <Has the Patient consented to this referral ?>	

Further Details	
 <Further Details>	
Comments/Recommendation for assessment or services	
 <Recommendation for assessment or services>	
	
Attachments Included	
	
	  Health Summary		 Inbound Referral Information	
				
	  Guardianship Order		 Financial Management/Admin Order	
				
	  Sensitive Client Status		 Clinical Notes	
				
	  Assessment Tool		 Advance Care Directive	
				
	  Other		 	

	
	
						Health Summary (if appropriate)

	Current Medications
	<SelectedRx>

	Past Medical History
	<SelectedPMH>

	Allergies
	<Reactions>

	Immunisations
	<Imm>

	Family/Social
	<FamilyHx>
	<SocialHx>