myagedcare

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

Recipient details			
Title		 <<Patient Demographics:Title>>	
First name		 <<Patient Demographics:First Name>>	
Last name		 <<Patient Demographics:Surname>>	
Date of birth		 <<Patient Demographics:DOB>>	
Gender		 <<Patient Demographics:Sex>>	
Marital Status		 <<Patient Demographics:Marital Status>>	
Indigenous/Cultural status		 <<Patient Demographics:Ethnicity>>	
Language spoken at home/ interpreter		 <<Language spoken at home>>  <<Interpreter ?>>	
Medicare number		 <<Patient Demographics:Medicare Number>>	
IRN			
DVA number		 <<Patient Demographics:DVA Number>>	
			
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		 <<Patient Demographics:Address Line 1>>	
Address line 2		 <<Patient Demographics:Address Line 2>>	
Suburb/Town		 <<Patient Demographics:City>>	
State		 Tasmania	
Postcode		  <<Patient Demographics:Postcode>>	
Can the client be assessed over the phone?		 <<Can the Client be assessed over the phone>>	
Phone Number		 (h) <<Patient Demographics:Phone (Home)>>  (m) <<Patient Demographics:Phone (Mobile)>>	
Call back day		 <<Cllient availability call back days -list all>>	
Call back time		 <<Preferred Client Call Back time>>	
			
Date of Referral		 <<Miscellaneous:Date (short)>>	

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		  <<Miscellaneous:Current User>>	
		 	
Practice Name		  <<Practice:Name>>	
Address		  <<Practice:Address>>	
State		  Tasmania	
Phone		  <<Practice:Phone>>	
Fax		  <<Practice:Fax>>	
Email		 	
			
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
	<<Clinical Details:Medication List>>

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

	Allergies
	<<Clinical Details:Allergies/Adverse Reactions>>

	Immunisations
	<<Clinical Details:Immunisation List>>

	Smoking/Alcohol
	<<Clinical Details:Alcohol>>
	<<Clinical Details:Smoking>>

	Family/Social
	<<Clinical Details:Family History>>
	<<Clinical Details:Social History>>