Calvary Clinic 			
Referral form (for use in GP Practice Software Applications)
Name: <<Patient Demographics:Full Name>>	D.O.B: <<Patient Demographics:DOB>>	
Address: <<Patient Demographics:Address Preferred Line 1>>, <<Patient Demographics:Address Preferred City>>, <<Patient Demographics:Address Preferred Postcode>>	
Phone: (H) <<Patient Demographics:Phone (Home)>> 	(M)	<<Patient Demographics:Phone (Mobile)>>		(W) <<Patient Demographics:Phone (Work)>>	
Referral to Dr <<Referral to Dr>>	Date to be admitted: <<Date to be admitted>>	
Insurance details	
Health Insured o
Fund:
Member No:	Workers Comp  o
Contact Name:
Number:	
Veterans Affairs  o
DVA No: <<Patient Demographics:DVA Number>>	MAIB  o
	
Reason for admission	<<Reason for admission>>	
Current Medical Conditions	<<Clinical Details:History List>>	
Allergies	<<Clinical Details:Allergies/Adverse Reactions>>	
Medications	<<Clinical Details:Medication List>>	
Risk Issues	 Suicide o		 Drug-Alcohol	o		 Aggressiono
 Self-harm	o	 Cognitive impairment o	 Othero	
State if risk is Low/ Moderate/ High/ Extreme and elaborate as required:

Referring Doctor’s name: <<Doctor:Name>>
Provider number: <<Doctor:Provider Number>>
Signature: 												Date: <<Miscellaneous:Date>>
Initial contact – please phone – (03) 6335 3249 then fax completed form to (03) 6335 3248