Referral to	
Integrated Team Care - Care-Coordination
Circular Head Aboriginal Corp   
(PO Box 335)
Smithton	TAS 	7330
Phone: (03) 6452 1287 
Mobile: 0400 861 550
Fax: (03) 6452 1187		

Thank you for seeing:
Patient Information	
First name: <PtFirstName>	Surname: <PtSurname>	
Gender: <PtSex>	Date of birth: <PtDoB>	
Address: <PtStreet>, <PtCity>, <PtPostcode>	
Home phone: <PtPhoneH>	Mobile: <PtPhoneMob>	
Medicare number: <PtMCNo>	Pension number: <PtPensionNo>	

My patient fulfils this criteria (please select)
	Is Aboriginal, has given me verbal or written consent to participate in this program 	

	GP Management Plan or Team Care Arrangement Plan is attached	

Has one or more of the following chronic diseases: (please X all that apply)
	Cancer	

	Cardiovascular	

	Diabetes	

	Renal Disease	

	Respiratory Disease	

	Asthma	

	Other (please list): 	

Services Required: (please X all that apply)
	Care Coordination	

	Specialist Care	

	Allied Health	

	Transport	

	Other (Please list): 	

Equipment Required: (please X all that apply)
	Dose Administration Aids	

	Blood Glucose Monitoring Equipment	

	Medical Footwear prescribed and fitted by Podiatrist	

	Adult Spacer	

	Child Spacer and Mask	

	Nebuliser and Mask	

	CPAP Machine 	

	CPAP Accessories	

	Other (Please list): 	

Comments/ Any other relevant information (please detail below)	

Past Medical History	
<SelectedPMH>	

Current Medications	
<SelectedRx>	

Allergies/ Adverse Reactions	
<Reactions>	

Investigations	
<Ix>	

Referrer Details 	
GP name: <DrName>	Provider number: <DrProviderNo>	
Practice name: <Practice>	
Address: <DrStreet>, <DrCity>, <DrPostcode>	
Phone: <DrPhone>	Fax: <DrFax>	Date: <TodaysDate>