Asthma Australia - Referral Service

Secure electronic transfer to: FA40060001U (Medical Objects)  asthmaus (HealthLink) 
or fax to: 07 3257 1080

The Asthma Australia Referral Service is available for patients over three years. 

Date of Referral: <TodaysDate>

RE: <PtName>
DOB: <PtDoB>
Address: <PtStreet>
Telephone: <PtPhoneH>			
Mobile: <PtPhoneMob>
Gender: <PtSex>

Reason for referral:
<Reason for referral >

Current Medications:<SelectedRx>

Referrer Details: 
Name of Doctor: <DrName>
Practice: <Practice>
Address/Post code: <UsrAddress> 
Telephone: <UsrPhone>
Fax:  <UsrFax>

	

Signed electronically: <DrName>

Patient Consent
Consent has been obtained from this patient/carer to provide their contact details to Asthma Australia for provision of free asthma education and support.

Asthma Australia Referral_v2.0_200601