SWSPHN Covid-19 Monitor Project Referral Form		

Enquiries: 4632 3000
Referrals to be sent via fax: +61 2 9475 0690
1.	Please include a patient Health Summary along with your referral
2.	Please Note: High-risk patients with significant Risk Factors / Co-Morbidities will be managed by SWSLHD. If you have a high-risk patient, you can refer them to the SWSLHD Clinical Escalation Line (open 7 days a week, 8:30-5:00pm) on 0460 021 244 
3.	Patients who are considered high risk include: 
•	People aged 60 years and older
•	Pregnant women 
•	Aboriginal, Torres Strait Islander and Pacific Islander people (from age 35 years and over)
•	People with obesity, diabetes, serious cardiovascular disease, chronic lung disease, severe chronic liver or kidney disease, active cancer or who are immunocompromised
•	Some people with a disability including those with a disability that affects their lungs, heart, or immune system
•	Residents of aged care and disability care facilities
•	People aged 18 years and older who are unvaccinated.

If the patient meets the criteria below, you may refer the patient to the SWSPHN Covid-19 Monitor Project. 
Is the patient < 65 years old?
<Is the patient < 65 years old?>

Age: <PtAge>
	No High Risk Factors?
 
<No High Risk Factors?>	Asymptomatic or / Mild Symptoms? 
<Asymptomatic or / Mild Symptoms?>	

Referrals cannot be accepted without the Patient’s, Parent or Guardian Signed Consent 
PLEASE PRINT CLEARLY
GP Details
Date:  
<TodaysDate>	GP Name: 
<DrName>	Practice Name: 
<LocationName>	
Practice Suburb:  	GP Phone:
	
GP Email:
<DrEmail>	GP Fax:
<DrFax>	

Patient Details
Title:
<PtTitle>	First Name:
<PtFirstName>	Last Name:
<PtSurname>	
Mobile / Best Contact Number: 
<PtPhoneMob>	Date of Birth:
<PtDoB>	Email:
<PtEmail>	
Sex: 
<PtSex>	Ethnicity (inc. Aboriginal & Torres Strait Islander status):
<PtEthnicity>	
Interpreter required: <Interpreter required>
Language: <If yes, language:>	Does the patient have difficulty with Hearing:
<Does the patient have difficulty with Hearing:>	
If the patient lives with other people, is there anyone else in the household that is infected with Covid-19 and requires monitoring as well? (Optional / If known)
<If the patient lives with other people, is there anyone else in the household that is infected with Covid-19 and requires monitoring as well?>
If yes, provide details: <If yes, provide details>	
<If the practice has iRAD installed, has the patient consented? (If yes, you may be able to access updated information in real-time. If the practice has iRAD, it is highly recommended for you to consent the patient at the time of referral)>If the practice has iRAD installed, has the patient consented? (If yes, you may be able to access updated information in real-time. If the practice has iRAD, it is highly recommended for you to consent the patient at the time of referral) 

Parent / Carer / Guardian Details
If the patient is under 18 years of age and has a Parent / Carer or Guardian or if the patient is over 18 years of age and needs a Carer / Guardian, please enter the following details:
Name:
<NOKName>	Relationship:
<NOKRelation>	Phone:
<NOKContact>	

Emergency / Next of Kin (NOK) Contact Details – if different from above
Name:
	Relationship:	Phone:	

Timeline of Illness
Date of Symptom Onset:
<Date of Symptom Onset:>
	Date of positive result:
<Date of positive result:>	

Vaccination Status
Vaccination Status:
<Vaccination status>

	Name of Vaccine/s:
<Name of Vaccine/s:>	Date of last Vaccination:
<Date of last Vaccination:>	

Previous Covid-19 Infection (Optional / if known)
Patient has previously been infected with COVID-19?  <Patient has previously been infected with COVID-19?>

Treatment received? <Treatment received?>

Date of last infection <Date of last infection>

Baseline Observations (if patient has given these details via telehealth consult)
Oxygen Saturation:
<Oxygen Saturation:>	Pulse Rate:
<Pulse Rate:>	Respiration Rate:
<Respiration Rate:>	Temperature:
<Respiration Rate:>
	Blood Pressure: 
<Blood Pressure:>	

Covid-19 Symptoms
<COVID-19 Symptoms (Select all that apply)>
<Other Symptoms>

Thank you for agreeing to contact __<PtFullName>______
I have gained consent for this referral from the patient (parent / carer / guardian if acting on behalf of patient).
I request that this patient be allocated to the SWSPHN Covid-19 Monitor Project.  
Patient / Parent / Carer / Guardian Section:
Patient Consent
 Referrers must confirm that they have read out the following information to the client and they understand and has given (informed) verbal consent: 
•	to the program as it has been described to you by your referrer
•	to your information being shared between the service provider and the funding body South Western Sydney PHN (SWSPHN), in accordance with the Privacy Act 1988
•	to being contacted by the allocated participating nurse who will be providing clinical care
•	to being contacted by the service provider, SWSPHN or its representative to complete a client experience of service survey or undertake other evaluation activities
Consumer, parent/carer or guardian consents to this referral and agrees to information about their COVID-19 status being recorded in their medical file and shared between the patient’s regular GP, South Western Sydney PHN COVID-19 Central Intake to assist in the management of their health care and the Registered Nurse to whom they are referred.
Yes	          No
The consumer understands that SWSPHN will provide information that does not identify them, such as the types of service they receive, for the purpose of research including informing on-going projects, and data around long-COVID 
Yes	          No

Consent to Leave a Message (if patient, parent, carer or guardian are not able to be contacted): 
Tick all that apply: 
  Voicemail on Home and or Mobile Phone Number
 SMS Text Message on Mobile Phone Number, if listed above
 Email to email address, if listed above
 With the Emergency / Next of Kin (NOK) contact person, as listed above 

OFFICE USE ONLY:
Date Referral Received:
	Received By: