Referral To	
(URGENT/IMMEDIATE REFERRALS ARE NOT SENT TO CRS, SEND DIRECTLY TO HOSPITAL)
Speciality:	<<Speciality>>
Name of Specialist (if required):	<<Name of Specialist>>
Site:	<<Site>>
Referral From	
Name:	<<Doctor:Name>>
Provider Number:	<<Doctor:Provider Number>>
Phone:	<<Practice/Location:Phone>>	                        Fax: <<Practice/Location:Fax>>
Address:	<<Doctor:Full Address>>

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) <<UMRN>>	
First Name(s): <<Patient Demographics:First Name>>	Family Name: <<Patient Demographics:Surname>>	
Preferred Name: <<Preferred Name>>	Previous Name (e.g. Maiden): <<Previous Name>>	
Title: <<Patient Demographics:Title>>	Marital Status: <<Patient Demographics:Marital Status>>	
Country of Birth: <<Patient Demographics:Country of Birth>>  	Birth Date: <<Patient Demographics:DOB>>	
Gender: <<Patient Demographics:Gender>>		
ATSI Status: <<Patient Demographics:ATSI>>		

Address:
<<Patient Demographics:Full Address>>
Post code:	<<Patient Demographics:Postcode>>	Mailing Address (if different): 
<<Patient Demographics:Address Postal>>

Email: <<Patient Demographics:E-mail>>	
Telephone No:
Home: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	
Work: <<Patient Demographics:Phone (Work)>>
Fax: <<Patient Fax>>	

Special Needs: <<special needs>>
Is an interpreter required? <<interpreter required>>		If Yes, language/Dialect: <<Which Dialect?>>
Other Special needs: 	<<Other Special needs?>>

Medicare Eligible: <<medicare eligible>>	Medicare No: <<Patient Demographics:Medicare Number>>	Ref: 	Expiry: <<Patient Demographics:Medicare Expiry Date>>	

DVA Card Number:	<<Patient Demographics:DVA Number>>	DVA Card Type:	<<DVA Card type>>	
MVIT <<MVIT>>	Workers Compensation <<Workers compensation>>	

Next of Kin/Guardian 
Full Name: <<Patient Demographics:Next of Kin>>			
Relationship: <<Patient Demographics:Next of Kin Relationship>>	Phone: <<Patient Demographics:Next of Kin Phone>>	

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?     <<discussed with Registrar or Consultant>>  	(essential for Urgent Cases)
If yes, the clinician name:    <<Clinician Name>>
Site:	 <<site>>	Contact Number:	<<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:	<<Name of GP>>
Contact number:	<<Contact number>>
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?           <<suitable for a Telehealth consult>>
Length of Referral:                                                           <<Length of referral>>
Is this a renewed referral?                                               <<renewed referral>>
Reason for referring:

Clinical Information	
Observations	BMI: <<BMI>>                       Height: <<height>>                           Weight: <<weight>>	
Current Problem:	<<Current Problem>> 	
Past History:	<<Clinical Details:History List>>	
Current Medications:	<<Clinical Details:Medication List>>	
Allergies:	<<Clinical Details:Allergies/Adverse Reactions>>	
Other:	<<other clinical information>>	
Family:	<<Clinical Details:Family History>>	
Social History:	<<Clinical Details:Social History>>	

Relevant Investigations and Tests (please attach)

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

Other:	<<Other Notes>>

Doctor Name:	<<Doctor:Name>>	Provider Number:	<<Doctor:Provider Number>>

Designation:	<<Designation>>	Date: <<Miscellaneous:Date>>    
Hospital Use Triage Only:
Urgent:	Semi Urgent:	Routine:
Comments:
Name:	Signature:	Date: