General Practitioner (GP): <DrName>      	
GP Practice: <Practice>      	Phone: <UsrPhone>   	
Preferred Method of Contact: <GP preferred method of contact>      	
Practice Name: <Practice>       	
Practice Hours: <Practice hours (24hr time)>       	
Does the Practice have an after-hours service? <Practice has an after-hours service>	
What time does the after-hours service operate? <What time does the after-hours service operate (24hr time)?>      	
Can GP Assist be contacted outside of these hours? <GP Assist can be contacted outside of these hours>	

Client Name: <PtFullName>      	Date of Birth: <PtDoB>   	
Address: <PtAddress>   	
Phone: <PtPhoneH>      	

Client Diagnosis: <Client diagnosis>       	
In the absence of ComRRS, would you have referred this client to the Emergency Department? <In the absence of ComRRS, would have referred this client to the Emergency Department>	

Treatment Plan/Action Required: <Treatment plan/action required:> 	
Community medication chart supplied to client? <Community medication chart supplied to client>	
Prescription supplied to client? <Prescription supplied to client>	
Client Medical History supplied? <Client medical history supplied>	
Copy of the clients GP Management Plan (GPMP) /Team Care Arrangement (TCA) (if relevant): <Copy of the clients GP Management Plan (GPMP)/Team Care Arrangement (TCA) supplied ( if relevant):>	
GP Review Date: (if required) <GP review date (if required):>       	
GP maintains clinical governance of the client whilst working in a shared care arrangement with ComRRS	
Print Name: <UsrName>      	Designation:      	
Signature:      	Date: <TodaysDate>