EMR64.1

ALLIED HEALTH AND COMMUNITY REHABILITATION

East Metropolitan Health Service
SINGLE POINT OF REFERRAL ALLIED HEALTH AND COMMUNITY REHABILITATION

SITE:   		Family Name	URN	
	Given Names	
	Address	
	D.O.B.	Gender	
Site referring to (please tick):
Armadale Health Service: phone1300 884 502 / 93912512 fax 93912262 email akg.referrals@health.wa.gov.au
Bentley Health Service: phone 9416 3213 fax 9416 3688	
Information for General Practitioners
Fax this form directly to the hospital site.
Patients requiring medical assessment should be referred via the Central Referral Service.
Referrals for Cardiovascular and Pulmonary Rehabilitation require a confirmed diagnosis.	
PATIENT DETAILS – complete or attach	
Previous name/s:	
Phone:	Mobile:	Email:	
Country of Birth:	Indigenous status: Aboriginal / Torres Strait Islander	
Interpreter required:  Yes    No	Language and dialect:	
NOK:	Relationship:	Phone:	
Medicare Number:	Ref. no:	Exp:	
DVA health card:	 Gold  White    Orange	
GENERAL PRACTITIONER DETAILS	
GP name:	Ph:	Fax:	
Practice Name:	Email:	
RELEVANT MEDICAL SPECIALIST DETAILS (e.g. Cardiologist, Respiratory Physician)	
Name:	Hospital/Site	
SERVICE REQUEST	
 Community Rehabilitation
(Interdisciplinary rehabilitation team)
 Falls Specialist
 Medical Review (internal referrers only)
 Cardiovascular Rehabilitation (CVR)
 Pulmonary Rehabilitation (PR)	 Clinical Psychology	
	 Dietetics	
	 Nursing	
	 Occupational Therapy	
ACAT (Aged Care Assessment Team)
 Permanent care	 Respite
 Services at home	 Physiotherapy	
	 Podiatry	
 CAEP (Community Aids & Equipment Program)	 Social Work	
 Continence clinic	 Speech Pathology	

Please use I.D. label or block print

HCEZXFMR0641

EMR64.1 08/16

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Please use I.D. label or block print
East Metropolitan Health Service
SINGLE POINT OF REFERRAL ALLIED HEALTH AND COMMUNITY REHABILITATION

SITE:   		Family Name	URN	
	Given Names	
	Address	
	D.O.B.	Gender	
REASONS FOR REFERRAL/CLIENT CENTRED GOALS	

	

	

MEDICAL HISTORY / STATUS (PMHx, allergies, precautions, red flags)
 Investigation results/medications/medical summary attached	 Discharge summary attached
For CVR & PR referrer must provide: details of Oxygen Therapy; Lung Function (FEV1 & FVC required for PR).
if available: 6 minute walk test, echo report, stress test, angiogram, ventricular function;
if applicable: ICD, PPM, PASP, PCI, stents.	

	
	
Current exercise / activity tolerance:	
SOCIAL SITUATION (eg living arrangements, carers, services in situ, red flags)
 Documents attached	 Safety risk for staff visits – advise below	

	

REFERRER DETAILS (if listed GP sign and date only)	
Name:	Title/Position:	
Phone:	Fax:	Email:	
Address/Location:	
Feedback requested    Yes	 No	
Signature:	Date:	
TRIAGE SUMMARY
TRIAGE OFFICER USE ONLY – REFERRERS DO NOT COMPLETE	

Service(s):	 Clinician(s)/Clinic(s): 		
Priority:
 Urgent  	
 Semi-urgent  	
 Routine 		
Comments:	
Triage Officer:	Signature:	Date:	

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