THS-South PAEDIATRIC REFERRAL FORM
<<Clinic Group>>
<<Community Physio Location>>
	PATIENT DETAILS                         (optional fields*)	

*THCI	

Patient Name:  <<Patient Demographics:Full Name>>	

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

Medicare No:  <<Patient Demographics:Medicare Number>>	

DOB:  <<Patient Demographics:DOB>>		Gender:  <<Patient Demographics:Sex>>	

Address: <<Patient Demographics:Full Address>>	

Parent/Guardian:  <<Head of Family:Full Name>>	

Relationship to Patient:  <<Head of Family:mother/father>>	

Phone (h):  <<Parent/Guardian Phone No>>	

Mobile:  <<Parent/Guardian Mobile No>>	

Alternate Contact:   	

		Referrers Name:  <<Doctor:Name>>	

Provider No:  <<Doctor:Provider Number>>	

Practice Address:  <<Doctor:Full Address>>	

Phone:  <<Doctor:Phone>>    Fax:  <<Doctor:Fax>>	

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:  <<Miscellaneous:Date (short)>> 	
Allergies:  <<Clinical Details:Allergies>>	
Past Medical History:  including birth and developmental history (if relevant):
<<Clinical Details:History List>>	
Current Medications:
<<Clinical Details:Medication List>>	
Relevant Social, Family or Occupational History:  Please add any information that will assis in the triage of this patient
<<Clinical Details:Social History>>
Current School: <<Current school of attendance >>
Current Grade: <<Current grade at school?>>	
Seen Before: <<Has the patient been seen before>>  		Interpreter Required:  <<Interpreter Required>> 	Language: <<Language>>	
Investigations:
 <<Summary:Investigation Results (Selected)>>