Surname: <PtSurname>
First name: <PtFirstName>
DOB: <PtDoB>	
REQUEST FOR OUTPATIENT APPOINTMENT - Paediatric	
(URGENT/IMMEDIATE REFERRALS ARE NOT SENT TO CRS, SEND DIRECTLY TO HOSPITAL)
Speciality:	<Referral to: Speciality>
Name of Specialist (if required):	<Referral to: Name of specialist (if required)>
Site:	<Referral to: Hospital>
Referral From	
Name:	<DrName>
Provider Number:	<DrProviderNo>
Phone:	<DrPhone>	Fax: <DrFax>
Address:	<LocationName>
	<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/mainden name:>
Title:	<PtTitle>	Marital Status:	<PtMaritalSt>
Country of Birth:	<Patient country of birth>	Birth Date:	<PtDoB>
If born in WA, name of Hospital:	<If born in WA, name of Hospital:>	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: 	<Patient other special needs?>
Medicare Eligible:	<Is the patient Medicare Eligible?>	Medicare No:	<PtMCNo>	Ref: <PtMCLine>	Expiry: <PtMCExpiry>
DVA Card Number:	<PtDVANo>	DVA Card Type:	<PtDVACard>
MVIT <Patient MVIT:>	Workers Compensation <Workers Compensation>
Next of Kin/Guardian 
Full Name:	<NOKName>
Relationship:	<NOKRelation>	Phone: 	<NOKContact>
Mother's name at time of birth:	<Patient's Mother's name at time of birth:>
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:	<If yes, the site name>	Contact Number:	<If yes, the site contact number>
Referral advice given: <Referral advice 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:
Percentile, Height & Weight:	<Observations (percentile):>
<Observations>	
Current Problem:	<Clinical Information: Current problem>	
Past History:	<SelectedPMH>	
Current Medications:	<SelectedRx>	
Allergies:	<Reactions>	
Other:	<Other clinical information:>	
Family:	<FamilyHx>	
Social History:	<SocialHx>	

Relevant Investigations and Tests (please attach)

Pathology Provider:	<Pathology Provider Name>	Radiology Provider:	<Radiology Provider Name>

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>