SWSLHD HIGH RISK FOOT SERVICE REFERRAL FORM

Bankstown HRFS accepts referral by Fax: 97228366 or Email: SWSLHD-Bankstown-HRFS@health.nsw.gov.au
Campbelltown HRFS accepts referrals by Fax 4634 4701 or Email: SWSLHD-MacarthurHighRiskFoot@health.nsw.gov.au
Liverpool HRFS accepts referrals by Fax: 8738 8297 or Email: SWSLHD-liverpoolhrfsreferral@health.nsw.gov.au

Patients living outside of the catchment area of SWSLHD are NOT eligible for referral

Dear: <<Addressee:Name>>         Date of Referral:<<Miscellaneous:Date (long)>>

PATIENT INFORMATION		
SURNAME: <<Patient Demographics:Surname>>	GIVEN NAME:<<Patient Demographics:First Name>>	
SEX: <<Patient Demographics:Gender>>	DATE OF BIRTH: <<Patient Demographics:DOB (long)>>	
ADDESS:<<Patient Demographics:Address>>	ABORIGINAL AND TORRES STRAIT ISLANDER STATUS: <<Patient Demographics:ATSI>>	
<<INTERPRETER REQUIRED?>>	<<IF YES, WHICH LANGUAGE?>>	

REFERRAL DETAILS:		
REFERRAL REASON:	<<Referral Reason:>>	
WOUND HISTORY:	<<Duration of Wound>>	
WOUND LOCATION:
	<<Wound Location>>	
WOUND CAUSATION DETAILS:	<<Wound Causation Details>>	
PREVIOUS TREATMENT:	<<Previous Treatment>>	
FURTHER COMMENTS/INFORMATION:	<<Additional Comments/Information>>	

Please attach medical history and medications. Include all relevant pathology (HbA1c, eGFR and CRP), relevant investigations (x-rays, vascular studies, microbial results) and a clear wound photo.

REFERRING CLINICIAN DETAILS:		
<<Doctor:Name>>	<<Doctor:Phone>>	
<<Doctor:Address>>	<<Doctor:Provider Number>>	
<<Doctor:E-mail>>	<<Doctor:Fax>>