Surname: <PtSurname>
Firstname:<PtFirstName>
DOB: <PtDoB>	
REQUEST FOR OUTPATIENT APPOINTMENT – General Adult	
(URGENT/IMMEDIATE REFERRALS ARE NOT SENT TO CRS, SEND DIRECTLY TO HOSPITAL)
Speciality:	<Speciality>
Name of Specialist (if required):	<Name of Specialist>
Site:	<Hospital>
Referral From	
Name:	<DrName>
Provider Number:	<DrProviderNo>
Phone:	<DrPhone> 	Fax: <DrFax>
Address:	<Practice>
	<DrStreet>
	<DrCity>, <DrState> <DrPostcode>
Once completed, please send referral to the Central Referral Service by one of the following methods.  
Please note that for efficiency of process our preferred method is Secure Messaging.
Secure Messaging	Healthlink address ID: crefserv
See the CRS website for more information on available vendors.
http://ww2.health.wa.gov.au/Articles/N_R/Referral-form-templates	
Fax	1300 365 056	
Post	Central Referral Service
GPO Box 2566
St Georges Terrace, WA 6831	
Patient Details	
	URMN Hospital No: (if known) <URMN Hospital No: (if known)>
First Name(s):	<PtFirstName>	Family Name:	<PtSurname>
Preferred Name:	<PtPrefName>	Previous Name (e.g. Maiden):	<Patient previous name:>
Title:	<PtTitle>	Marital Status:	<PtMaritalSt>
Country of Birth:	<Patient Country of Birth>	Birth Date:	<PtDoB>
Gender:	<PtSex>
ATSI Status:	<Patient ATSI status>
Address:
<PtStreet>, <PtCity> <PtState>
Post code:	<PtPostcode>	Mailing Address (if different): 
<PtPOAddress> <PtPOCity> <PtPOPostcode>
Email: <PtEmail>	
Telephone No:
Home:	<PtPhoneH>
Mobile:	<PtPhoneMob>	
Work:	<PtPhoneWk>
Fax:	<Patient fax number>	
Special Needs: 
Is an interpreter required?	<Is an interpreter required?>	If Yes, language/Dialect: <If Yes, language/Dialect>
Other Special needs: 	<Other Special needs>
Medicare Eligible:	<Medicare eligible?>	Medicare No: <PtMCNo>	Ref: <PtMCLine> Expiry: <PtMCExpiry>
DVA Card Number:	<PtDVANo>	DVA Card Type:	<PtDVACard>
MVIT <Patient MVIT>	Workers Compensation <Worker's Compensation>
Next of Kin/Guardian 
Full Name:	 <NOKName>
Relationship:	<NOKRelation>	Phone: 	<NOKContact>
Referral Details	
Fill this box for Immediate Referrals only (if the Patient must be seen by specialist within 7 days)
Has the referral been discussed with Registrar or Consultant?      <Has the referral been discussed with Registrar or Consultant?>	(essential for Urgent Cases)
If yes, the clinician name:    <If yes, the clinician name>
Site:	<Site name>	Contact Number: <Referrer contact number>
Referral advice given: <Referral Advise given>	
Is the referrer the usual GP for the patient?	<Is the referrer the usual GP for the patient?>
If No, name of usual GP:	<If No, name of usual GP>
Contact number:	<If No, phone number of usual GP>
If the patient has been referred to this speciality for the same condition before, do they need to be referred to the same place again?	<Does patient need to be referred to the same place?>
Is the patient suitable for a Telehealth consult?	<Is the patient suitable for a Telehealth consult?>
Length of Referral:	<Length of Referral>
Is this a renewed referral?	<Is this a renewed referral?>
Reason for referring:
<Reason for referring>
Clinical Information	
Observations
BMI, Height & Weight	<Observations>	
Current Problem:	<Current problem>	
Past History:	<SelectedPMH>	
Current Medications:	<SelectedRx>	
Allergies:	<Reactions>	
Other:	<Other Clinical Information>	
Family:	<FamilyHx>	
Social History:	<SocialHx>	

Relevant Investigations and Tests

Pathology Provider:	<Pathology provider>	Radiology Provider:	<Radiology Provider>

Other Notes: <Other notes:>

Doctor Name:	<DrName>	Provider Number:	<DrProviderNo>
Designation:	<Doctor designation>	Date:	<TodaysDate>
Hospital Use Triage Only:
Urgent:	Semi Urgent:	Routine:
Comments:
Name:	Signature:	Date:

<Ix>