Tasmanian Health Service	
 Palliative Care Services				
<<Palliative Care region>>	

Referral Form		
	PATIENT DETAILS:	
	Surname:	<<Patient Demographics:Surname>>	
Given Names:	<<Patient Demographics:First Name>>	

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

Address:		<<Patient Demographics:Address>>  <<Patient Demographics:Address Line 2>>  <<Patient Demographics:City>>  <<Patient Demographics:Postcode>>	
Marital Status:	<<Patient Demographics:Marital Status>>	

Gender:		<<Patient Demographics:Sex>>	
Mobile:		<<Patient Demographics:Phone (Mobile)>>	

Medicare: <<Patient Demographics:Medicare Number>>	

Home Phone:	<<Patient Demographics:Phone (Home)>>	
Work Phone:	<<Patient Demographics:Phone (Work)>>	

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:	<<Doctor:Name>>	Phone: 	<<Doctor:Phone>>	
Practice: <<Doctor:Full Address>>	Fax:	<<Doctor:Fax>>	   
Email:  <<Doctor:E-mail>>	
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:		<<Doctor:Name>>	Phone:	<<Doctor:Phone>>	
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: <<Doctor:Name>>  Date: <<Miscellaneous:Date>>	Signature:
<<NB>>	
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

	<<Clinical Details:History List>>

Medications

	<<Clinical Details:Medication List>>

Allergies

	<<Clinical Details:Allergies>>

Pathology

	<<Summary:Investigation Results (Selected)>>