General Practitioner (GP): <<Doctor:Name>>		
GP Practice: <<Practice:Name>>     	Phone: <<Practice:Phone>>  	
Preferred Method of Contact: <<GP Preferred Method of Contact>>     	
Practice Name: <<Practice:Name>>      	
Practice Hours: <<Practice Hours (24 hours 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 after hours service operate?>>     	
Can GP Assist be contacted outside of these hours? <<GP Assist can be contacted outside these hours>>	

Client Name: <<Patient Demographics:First Name>>     	Date of Birth: <<Patient Demographics:DOB>>  	
Address: <<Patient Demographics:Address>>  	
Phone: <<Patient Demographics:Phone (Mobile)>>     	

Client Diagnosis: <<Client diagnosis>>      	
In the absence of ComRRS, would you have referred this client to the Emergency Department? <<Would have referred pt to ED without CommRRS>>	

Treatment Plan/Action Required: <<Treatment Plan/Action Plan 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): <<GPMP/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: <<Doctor:Name>>     	Designation:      	
Signature:      	Date: <<Miscellaneous:Date (short)>>