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 <AdrName>                                               Date of referral: <TodaysDate> 
Patient Information	

Family name: <PtSurname>	
Given Names: <PtFirstName>	

Sex: <PtSex>	
Date of Birth: <PtDoB>	

Address: <PtStreet> <PtCity> <PtState> <PtPostcode>	
Aboriginal and Torres Strait Islander Status: <ATSI status>	

Contact number: <PtPhoneH>  <PtPhoneMob>	
Alternative contact number: <Alternative contact number>	

Interpreter Required: <Interpreter Required>     Language: <Language Preferred>	

Referral Details	

 <Referral Reason:>Please tick, needs meet at least of the following referral criteria:

  Wound History:  
<Wound Location>    
 <Foot> 
<Duration of Wound>	

  Please note if wounds are above the ankle, please refer to Community Nursing via Triple-I Hub

<Wound casuation details>

  Previous treatment (please tick and enter details if required)
<Previous Treatment>
<Previous treatment details>

  Please attach medical history, medications and clear wound photo to this referral.

  Please include all relevant pathology including HbA1c, eGFR and CRP, and relevant investigations   
  such as x-rays and vascular studies, and microbial results.	

Referring clinician	

Referrers Name: <DrName>	
Phone: <DrPhone>	

Address/Practice Name: <UsrAddress>/ <Practice>	
Provider Number (if applicable): <DrProviderNo>	

Email: <DrEmail>	
Fax: <DrFax>