REFERRAL FORM
CRITERIA FOR REFERRAL 	
COVID@homeplus is an extension of the existing COVID@home service that aims to support vulnerable patients with influenza or other respiratory illnesses to provide additional monitoring and support during their acute illness. Patients must meet one or more of the below criteria to be eligible. 
Further information is available at www.coronavirus.tas.gov.au/families-community/covidathomeplus and on the Tasmanian Health Pathways https://tasmania.communityhealthpathways.org/919438.htm
Referrals will be reviewed within 12-24 hour time frame.
•	< 5 years of age especially < 6 months
•	≥ 65 years of age
•	pregnant (including 2 weeks postpartum)
•	Aboriginal and Torres Strait Islander People 
•	chronic lung disease (including severe asthma)
•	other medical history (immunosuppressed, heart disease, obesity (BMI>40), diabetes, kidney disease) 
•	other people with influenza or ILI who do not fit the above criteria but where their health professional assesses that enrolment will support management to avoid hospital admission, or
•	any person with influenza or ILI where assessment by COVID@homeplus clinician indicates enrolment will likely avoid hospital admission with support from the program.

PATIENT INFORMATION	
Patient Name: <PtFullName>	Previous Name: 	
Medicare Number: <PtMCNo>	Date of Birth: <PtDoB>	
Address: <PtStreet>, <PtCity>, <PtPostcode>	
Home Phone: <PtPhoneH>   Mobile: <PtPhoneMob>	
Next of Kin: <NOKName>	Relationship: <NOKRelation>	Phone: <NOKContact>	
Interpreter Required: 	Interpreter language: 	

REFERRER DETAILS 	
GP Name: <DrName>	Provider number: <DrProviderNo>	
Practice Address: <DrAddress>	
Phone: <DrPhone>	Fax: <DrFax>	
Usual GP if not referrer: 	

DETERMINING RISK FACTORS (please ‘x)	

Please indicate if the patient has had the following:	

	

	

•	Influenza vaccination (2022)?	
	
Yes	
	
No	

	

	

•	COVID vaccination	
	
Yes	
	
No   Number of: 	

	

	

•	Negative COVID RAT	
	
Yes	
	
No   Date: 	

	

	

•	Negative COVID PCR	
	
Yes	
	
No   Date: 	

	

	

•	Respiratory PCR 	
	
Yes	
	
No (if no please request)	

	

	

Please indicate if the patient has any of the below factors:	

	

	

•	< 5 years of age especially < 6 months	
	
Yes	
	
No	

	

	

•	≥ 65 years of age	
	
Yes	
	
No	

	

	

•	pregnant (including 2 weeks postpartum)?	
	
Yes	
	
No	

	

	

•	Aboriginal and/or Torres Strait Islander?	
	
Yes	
	
No	

	

	

•	chronic lung disease (including severe asthma)	
	
Yes	
	
No	

	

	

•	cancer/ Immunocompromised 	
	
Yes	
	
No	

	

	

•	heart disease	
	
Yes	
	
No	

	

	

•	obesity (BMI >40)	
	
Yes	
	
No	

	

	

•	diabetes	
	
Yes	
	
No	

	

	

•	kidney disease	
	
Yes	
	
No	

	

	

•	Influenza or ILI who does who do not fit the above criteria but where their health professional assesses that enrolment will support management to avoid hospital admission	

Yes	
	
No	

	

	

	

	

	

	

COVID@home plus discharge patients after 7 days, consider organising a follow up appointment with patient in 10-14 days.	

	

REASON FOR REFERRAL (please detail below)	

ALLERGIES	
<Reactions>	

PAST MEDICAL HISTORY	
<SelectedPMH>	

CURRENT MEDICATIONS	
<SelectedRx>	

RELEVANT SOCIAL OR FAMILY HISTORY	
<SocialHx>
<FamilyHx>	

DATE OF REFERRAL 	
<TodaysDate>