THS-South PAEDIATRIC REFERRAL FORM
<<Clinic Group>>
<<Community Physio Location>>
	PATIENT DETAILS                         (optional fields*)	

*THCI	

Patient Name:    <<Patient Demographics:Full Name>>	

Previous Name:   <<Patient's previous name if Known>>	

Medicare No:   <<Patient Demographics:Medicare Number>>	

DOB:   <<Patient Demographics:DOB>>		Gender: <<Patient Demographics:Sex>>	

Address:   <<Patient Demographics:Full Address>>	

Parent/Guardian: 	<<Head of Family:Full Name>>	

Relationship to Patient:	<<Head of Family:mother/father>>	

Phone (h):   <<Parent/Guardian Phone No>>	

Mobile:   	<<Parent/Guardian Mobile No>>	

Alternate Contact:   	

		Referrers Name:    <<Doctor:Name>>	

Provider No:    <<Doctor:Provider Number>>	

Practice Address:   <<Doctor:Full Address>>	

Phone:  <<Doctor:Phone>>    Fax:  <<Doctor:Fax>>	

Usual GP if not referrer:   <<Usual GP if not referrer>>	

Referred to:    <<Aged Care Clinics>> <<Medical Clinics>> <<Paediatric Clinics>> <<Rehabilitation Clinics>> <<Surgical Clinics>> <<Women's Clinics>>	

*Specialist:   <<Intended Specialist if known>>	

GP Expectation of referral:	

	<<Your Expectation of referral>>		

Reason for Referral:

OFFICE USE ONLY		
Date Referral Registered:				  Initials: 	Clinic/Consultant: 	
  PA  q		NPA  q	 Cat 1			Cat 2			Cat 3	
Details: 	  RFC  q	
		
  Non-Acceptance  q	 Dr's Signature:	
 Reason (opt paragraph):	   Waitlisted  q	

Referral Details:                      Pre-referral information available at www.outpatients.tas.gov.au	

	
Signed:									Date: <<Miscellaneous:Date (short)>> 	
Allergies:  <<Clinical Details:Allergies>>	
Past Medical History:  including birth and developmental history (if relevant):

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

<<Clinical Details:Medication List>>	
Relevant Social, Family or Occupational History: Please add any information that will assist in the triage of this patient

<<Clinical Details:Social History>>	
	
Seen Before: <<Has the patient been seen before>>  		Interpreter Required:  <<Interpreter Required>> 		 Language: <<Language>>	
Investigations:
 <<Summary:Investigation Results (Selected)>>