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 aged over three years.  

Date of Referral: <<Miscellaneous:Date (short)>>

RE: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>
Telephone: <<Patient Demographics:Phone (Home)>>			
Mobile: <<Patient Demographics:Phone (Mobile)>>
Gender: <<Patient Demographics:Sex>>

Reason for referral:
<<Reason for referral >>

Current Medications:<<Clinical Details:Medication List>>

Referrer Details: 
Name of Doctor: <<Doctor:Name>>
Practice: <<Practice:Name>>
Address/Post code:<<Practice:Address>>  
Telephone: <<Practice:Phone>>
Fax:  <<Practice:Fax>>

	

Signed electronically: <<Doctor:Name>>

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 Service_v2.0_MD_200601