Podiatry South Referral Form
	PH: (03) 6166-2600   Fax: (03) 6234 5568

Date of Referral: <TodaysDate>		THS-Southern Region	

	Patient Details	Referring General Practitioner	
	THCI No: 
<PtName>
Medicare Number: <PtMCNo>
DOB: <PtDoB>
Gender: <PtSex>
<PtAddress>
PH: (H) <PtPhoneH>  
PH: (A) <PtPhoneWk>
Mob: <PtPhoneMob>	<DrName>
Prov. No. <DrProviderNo>
<Practice>
<DrAddress>

Ph:  <DrPhone> 
Fax: <DrFax>
Usual GP if not referrer: <Usual GP if not referrer?>

Preferred Language:    <Language Spoken>      Interpreter Required:   <Interpreter Required>	
Contact Person:     <Contact person>                Ph:  <Contact Person Number>	
Relationship:  <Contact Person Relationship>	

Podiatry does not accept EPC referrals but can be included as a participant in GPMP and TCA arrangements. Please consider whether the patient is suitable for referral to private podiatry services considering the prioritisation advice below. 	
Reason for referral (tick all that apply) *Wait times apply to low risk referrals	
Priority 1:
<Priority 1  Reason for referral (select all that apply)>	
*Priority 2:
<Priority 2  Reason for referral (select all that apply)>	
*Priority 3:
<Priority 3  Reason for referral (select all that apply)>	
Health risk factors (tick all that apply)	
<Health risk factors (select all that apply)>	
Additional Information: 
<Additional Information:>

Referrers Signature:                                                                                               <TodaysDate>	

<PtName> - Medications and Medical History	

Allergies:
<Reactions>

Medications:
<SelectedRx>

Medical History:
<SelectedPMH>