Tasmanian Health Service	
 Palliative Care Services				
<Palliative Care region>	

Referral Form		
	PATIENT DETAILS:	
	Surname:	<PtSurname>	
Given Names:	<PtFirstName>	

Patient No (9 Digit THCI)	
Date of Birth:	<PtDoB>	

Address:		<PtStreet>  <PtAddress Line 2>  <PtCity>  <PtPostcode>	
Marital Status:	<PtMaritalSt>	

Gender:		<PtSex>	
Mobile:		<PtPhoneMob>	

Medicare: <PtMCNo>	

Home Phone:	<PtPhoneH>	
Work Phone:	<PtPhoneWk>	

Currently resides at:  <Currently resides at (if different)>	

Patient has consented to this referral:	<Patient consents to referral>	
Patient Lives alone:	<Patient Lives alone>	

REFERRING GP:		
Requestor:	<DrName>	Phone: 	<DrPhone>	
Practice: <DrAddress>	Fax:	<DrFax>	   
Email:  <DrEmail>	
Is the Patient currently an inpatient:    <Patient is currently an  Inpatient>	Admission Diagnosis:  <Admission Diagnosis>	
If appropriate has Medical Specialist  been advised:  <If appropriate has patient's specialist been advised>		
Primary Health Care Providers currently involved in patient's /referral sent (mark applicable)	
  q	Community Nursing	  q	Physiotherapy	  q	Occupational Therapy	  q	Dietician		
  q	Hospice Volunteer		  q	Social Worker	  q	Other (specify)	 	
General Practitioner:		<DrName>	Phone:	<DrPhone>	
Medical Specialist:		<Med Specialist involved in care - Name>	Phone:	<Specialist Phone>	
Community Nurse:		<Comm nurse Involved in care - Name>	Phone:	<Comm Nurse phone>	
Other Primary Carer:		<Other Primary Carer - Name>	Phone:	<Carer Phone>	
Main Caregiver:		<Main Caregiver - Name>	Relationship	<Main Caregiver - Relationship to Patient>	
Address: 	<Main Caregiver - Address>	Phone:	<Main Caregiver - Home Phone>	
Work Phone:		<Main Caregiver - Work Phone>	Mobile:	<Main Caregiver - Mobile>	
Diagnosis/History/Changes (Full Health Summary contained on Page 2)	

Specific Issue and Reasons for Referral  (e.g. level of symptom control, needs identified and how they are managed)	
  q	Symptom Control	  q	Pain Management	  q	Nursing Support	  q	Psychosocial Support	
  q	Family Support		  q	Terminal Care	  q	Other (specify)	 	
				
Referral is:	<Referral Urgency>	Name of person informing client of this referra (if not GP):  <Name of person informing client of referral if Not GP>	
Is the patient known to Palliative Care?  <Patient is known to Palliative Care>	Is the patient aware of their diagnosis?  <Patient is aware of Diagnosis>	
Prognosis: (in your opinion) this patient has a prognosis of: 	  <In your opinion Patient prognosis>	
Referral faxed to Carepoint:  <Referral faxed to Carepoint (6224 2451)>	Goals of Care form completed?	<Has a Goals of Care form been completed>	
GP Name: <DrName>  Date: <TodaysDate>	Signature:
	
Palliative Care North: 	Ph: 6777 4544	Fax: 6336 5529 	E: palliativecare.north@ths.tas.gov.au 	
Palliative Care South: 	Ph: 6166 2820	Fax: 6224 2451 	E: pcsouth@ths.tas.gov.au 	
Palliative Care North West: 	Ph: 6440 7111	Fax: 6440 7113	E: palliativecareservicenw@ths.tas.gov.au	

  History

	<SelectedPMH>

  Medications

	<SelectedRx>

  Allergies

	<Reactions>

  Pathology

	<Ix>