The Post COVID-19 Syndrome Navigation Service is a Statewide service available to all Tasmanians 
16 years and over. This is NOT an emergency or urgent care service.	

PATIENT INFORMATION	
Patient Name: <<Patient Demographics:First Name>>	Surame: <<Patient Demographics:Surname>>	
Medicare Number: <<Patient Demographics:Medicare Number>>	Date of Birth: <<Patient Demographics:DOB>>	
Address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:Postcode>>	
Home Phone: <<Patient Demographics:Phone (Home)>>    Mobile: <<Patient Demographics:Phone (Mobile)>>	

INCLUSION CRITERIA (Patient must meet ALL the below inclusion criteria)	
	
		Tasmanian 16 years and over 	
	
		Patient with confirmed diagnosis of Post COVID-19 Syndrome 	
(three months post initial test with symptoms for at least two months)	
	
		Patient willing to participate in assessment and offered program support  	
	
EXCLUSION CRITERIA (Patient must NOT have any of the following exclusion criteria)	
- Patient who is COVID-19 positive with acute symptoms  	
- Patient with acute symptoms indicating need for emergency assessment	
- Referral for other pre-existing chronic conditions not related to COVID-19	

REASON FOR REFERRAL (attach screening tool if completed)	
Referral date: <<Miscellaneous:Date>>	Date of initial COVID-19 positive test: <<Date of initial COVID-19 positive test>>	
Symptoms of concern: <<Symptoms of concern>>	
Completed or requested investigations: <<Completed or requested investigations>>	
Additional referrals sent to other speciality clinics: <<Additional referrals sent to other speciality clinics>>	

MEDICAL HISTORY	
<<Clinical Details:History List>>	

MEDICATION HISTORY	
<<Clinical Details:Medication List>>	

ALLERGIES AND ADVERSE REACTIONS	
<<Clinical Details:Allergies/Adverse Reactions>>	

REFERRER DETAILS	
GP Name: <<Doctor:Name>>	Provider number: <<Doctor:Provider Number>>	
Practice: <<Practice/Location:Name>>	
Practice Address: <<Practice/Location:Address>>	
Phone: <<Practice/Location:Phone>>	Fax: <<Practice/Location:Fax>>	
Signature: 	Date: <<Miscellaneous:Date>>	

Email referrals to covidathomereferrals@ths.tas.gov.au or call COVID@homeplus direct line: 1800 973 363