GENERAL PRACTITIONER REFERRAL (must complete this section)	
PATIENT DETAILS	
Family name:  <<Patient Demographics:Surname>>	Given Names:  <<Patient Demographics:First Name>><<Patient Demographics:Middle Name>>	
Sex:  <<Patient Demographics:Gender>>	Date of Birth:  <<Patient Demographics:DOB>>	Age:  <<Patient Demographics:Age>>	
Address:  <<Patient Demographics:Address>><<Patient Demographics:City>><<Patient Demographics:State>><<Patient Demographics:Postcode>>	
Phone (H):  <<Patient Demographics:Phone (Home)>>	Phone (W):  <<Patient Demographics:Phone (Work)>>	Phone (M):  <<Patient Demographics:Phone (Mobile)>>	
Email:  <<Patient Demographics:E-mail>>	
Ethnicity / Aboriginal and Torres Strait Islander Status:  <<Patient Demographics:ATSI>>
Interpreter Required:  <<Patient Demographics:Requires Interpreter>> (if yes, language spoken): <<Patient Demographics:Language Spoken>>	
Medicare card no: <<Patient Demographics:Medicare Number>>	   IRN: <<MedicareIRN>>	 	Expiry: <<Patient Demographics:Medicare Expiry Date>> 
NOTE: If Medicare ineligible, fees will apply. Contact Triple I for details. 	
DVA Card Number: <<DVA Card Number>> 	       Card Type:  <<DVA Card Type>>
NOTE: If DVA Card Holder, refer to DVA unless Hospital Avoidance category of client.   	
Pension/Health Care Card No:  <<Patient Demographics:Pension Number>>	Private Health Insurer: <<Patient Demographics:Health Insurance>> 	
Marital Status:<<Patient Demographics:Marital Status>>  	Occupation:<<Patient Demographics:Occupation>>  	
Next of Kin Details: 
Name: <<Patient Demographics:Next of Kin>> 	 	 	 	 	 	Relationship to Carer: <<Patient Demographics:Next of Kin Relationship>>
Contact Number:<<Patient Demographics:Next of Kin Phone>>  
Address: <<Patient Demographics:Next of Kin Address>> 	
REFERRING MEDICAL OFFICER’S DETAILS	
Doctor's Name: <<Doctor:Name>>	 	 		
Phone:  <<Doctor:Phone>>   	Fax: <<Doctor:Fax>>	 	
Address:  <<Doctor:Address>><<Doctor:City>><<Doctor:Postcode>>		
Email:  <<Doctor:E-mail>>		
 	  
Clinical Details	
Relevant Medical History: 
<<Clinical Details:Allergies/Adverse Reactions>>  
<<Clinical Details: Relevant Medical History>>
  
Current Medications: 
<<Clinical Details:Medication List>>

SPECIALIST BEING REFERRED TO: 	
	
<<Please circle/nominate a Specialist>>:
*If another specialist has a shorter wait time, the patient could be contacted and offered an earlier appointment. A new referral is not required.	
MEDICAL HISTORY:  	
Weight (kg): <<Clinical Details:Measurements (Selected)>>                       	Height (m): <<Clinical Details:Measurements (Selected)>>     	
Previous colonoscopy:  <<Previous Colonoscopy?>>	If YES - year of last colonoscopy: <<If YES - year of last colonoscopy:>>	
CURRENT SYMPTOMS:		
<<Current Symptoms - Please indicate yes/no>>
		
CURRENT MEDICAL HISTORY  			
<<Current Medical History >>
<<Other issues- Please specify:>>

For FOBT DAC Referrals please attach the following documents to this referral form
0	Patient Health Summary
0	Positive FOBT result
0	Recent blood tests – FBE, UEC, LFT, Iron studies
0	Specialist Letters for relevant conditions
	
Date:  	Doctor’s signature: