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:	Hospital
Referral From	

Name:	Treating Doctor.Name
Provider Number:	Treating Doctor.Provider Number
Phone:	Practice.Phone	Fax: Practice.Fax
Address:	Practice.Name
	Treating Doctor.Address
	Treating Doctor.Suburb, Treating Doctor.Postcode
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	See the CRS website for more information on available vendors.
http://www.gp.health.wa.gov.au/crs/about/refferal-forms.cfm	
Fax	1300 365 056	
Post	Central Referral Service
PO Box 3462
Midland WA 6056	
Patient Details	

First Name(s):	Patient Demographics.First Name	Family Name:	Patient Demographics.Surname
Preferred Name:	Patient Demographics.Popular Name	Previous Name (e.g. Maiden):	Previous Name
Title:	Patient Demographics.Title	Marital Status:	Patient Demographics.Marital Status
Country of Birth:	Country of Birth	Birth Date:	Patient Demographics.DOB
Gender:	Patient Demographics.Gender
ATSI Status:	ATSI Status
Address:
Patient Demographics.Address, Patient Demographics.Suburb
Post code:	Patient Demographics.Postcode	Mailing Address (if different): 
Patient Demographics.Mailing AddressPatient Demographics.Mailing SuburbPatient Demographics.Mailing Postcode
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	

Is an interpreter required?	Interpreter	If Yes, language/Dialect: Which dialect
Other Special needs: 	Other special needs
Medicare Eligible:	Medicare Eligible	Medicare No:	Patient Demographics.Medicare Number	Ref: Medicare reference	Expiry: Medicare expiry
DVA Card Number:	Patient Demographics.DVA Number	DVA Card Type:	DVA Card Type
MVIT MVIT	Workers Compensation  Worker's Compensatio
Next of Kin/Guardian 
Full Name:	Patient Demographics.NOK Name
Relationship:	Patient Demographics.NOK Relationship	Phone: 	Patient Demographics.NOK Home 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?	Registrar contacted	(essential for Urgent Cases)
If yes, the clinician name:	Registrar Name
Site:	Registrar Site	Contact Number:	Registrar Contact
Referral advice given: Referral Advise give	

Is the referrer the patient's usual GP?	Usual GP
If No, name of usual GP:	Usual GP Name
Contact number:	GP Contact
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?	same place
Is the patient suitable for a Telehealth consult?	Telehealth
Length of Referral:	Length of referral
Is this a renewed referral?	Renewed Referral
Reason for referring:
Reason for referring
Clinical Information	
Observations
BMI, Height & Weight	Clinical Details.Selected Most Recent Measures	
Current Problem:	Clinical Details.Problem List (Current)	
Past History:	Clinical Details.Problem List (Resolved)	
Current Medications:	Clinical Details.Medications - Current Regular	
Allergies:	Clinical Details.Allergies	
Other:	Other Clincial Infor	
Family:	Clinical Details.Family History	
Social History:	Clinical Details.Social History	

Relevant Investigations and Tests

Pathology Provider:	Pathology Provider	Radiology Provider:	Radiology Provider

Other Notes: Other Notes

Doctor Name:	Treating Doctor.Name	Provider Number:	Treating Doctor.Provider Number
Designation:	Treating Doctor.Qualifications	Date:	Miscellaneous.Date
Hospital Use Triage Only:
Urgent:	Semi Urgent:	Routine:
Comments:
Name:	Signature:	Date: