THS-South PAEDIATRIC REFERRAL FORM
<Clinic Group>
<Community Physio Location>

	PATIENT DETAILS                         (optional fields*)	

*THCI	

Patient Name:    <PtName>	

Previous Name:   <Patient's previous name if Known>	

Medicare No:   <PtMCNo>	

DOB:   <PtDoB>		Gender: <PtSex>	

Address:   <PtAddress>	

Parent/Guardian: 	<HoFName>	

Relationship to Patient:	<NOKRelation>	

Phone (h):   <NOKContact>	

Mobile:   	<NOKContact2>	

Alternate Contact:   	

		Referrers Name:    <DrName>	

Provider No:    <DrProviderNo>	

Practice Address:   <DrAddress>	

Phone:  <DrPhone>    Fax:  <DrFax>	

Usual GP if not referrer:   <Usual GP if not referrer>	

Referred to:   <Medical Clinics> <Paediatric Clinics> <Rehabilitation Clinics> <Surgical Clinics> <Women's Clinics>	

*Specialist:   <Intended Specialist if known>	

GP Expectation of referral:	

	<Your Expectation of referral>		

Reason for Referral:

OFFICE USE ONLY		
Date Referral Registered:				  Initials: 	Clinic/Consultant: 	
  PA  q		NPA  q	 Cat 1			Cat 2			Cat 3	
Details: 	  RFC  q	
		
  Non-Acceptance  q	 Dr's Signature:	
 Reason (opt paragraph):	   Waitlisted  q	

Referral Details:                      Pre-referral information available at www.outpatients.tas.gov.au	

	
Signed:									Date: <TodaysDate> 	
Allergies:  <Reactions>	
Past Medical History:  including birth and developmental history (if relevant):
<SelectedPMH>	
Current Medications: <SelectedRx>	
Relevant Social, Family or Occupational History: Please add any information that will assist in the triage of this patient
<SocialHx>
Current School: <Current school of attendance?>
Currents grade: <Current Grade at school?>	
	
Seen Before: <Has the patient been seen before>  		Interpreter Required:  <Interpreter Required> 		 Language: <Language>	
Investigations:
 <Ix>