RURAL PRIMARY HEALTH SERVICE (RPHS) REFERRAL FORM
Please complete all sections and fax to (07) 4151 0794
Enquiries to: services@rhealth.com.au
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Patient details
Re: <<Patient Demographics:Full Name>>
DOB: <<Patient Demographics:DOB>>
Address: <<Patient Demographics:Address>>
Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Gender: <<Patient Demographics:Gender>>
Identifies as: <<Patient identifies as>>
CALD: <<Patient is culturally and linguistically diverse(CALD)?>>
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Mandatory
Patients living in RA 3-5 Areas with Chronic Disease, or risk of diagnosis.

Chronic Disease Patient being referred for
Asthma: <<Patient being referred for asthma?>>
Arthritis: <<Patient being referred for arthritis?>>
Cardio Vascular Disease: <<Patient being referred for cardio-vascular disease?>>
COPD: <<Patient being referred for COPD?>>
Obesity/Overweight: <<Patient being referred for obesity/overweight?>>
Diabetes: <<Patient being referred for diabetes?>>
Other: <<Patient being referred for other chronic disease?>>
Medical Reason for Referral: <<Medical Reason for Referral>>
Group Session: <<Group Session>>
Individual Session: <<Individual Session>>
Does this patient have a My Health Record? <<Patient has a My Health Record?>>
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**PLEASE ATTACH GP MANAGEMENT PLAN / TEAM CARE ARRANGEMENT**
Other supporting information attached:
Health Summary: <<Health Summary attached?>>
Pathology Results - Biochemistry: <<Pathology Results - Biochemistry attached?>>
Previous Medications/Surgical History attached: <<Previous Medications/Surgical History attached?>>
Current Medications: <<Current Medications attached?>>
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Allied Health Service (please tick all appropriate services required)
Biggenden - Diabetes Education: <<Biggenden - Diabetes Education required?>>
Biggenden - Podiatry: <<Biggenden - Podiatry required?>>
Eidsvold - Diabetes Education: <<Eidsvold - Diabetes Education required?>>
Eidsvold - Dietitian: <<Eidsvold - Dietitian required?>>
Eidsvold - Podiatry: <<Eidsvold - Podiatry required?>>
Gayndah - Diabetes Education: <<Gayndah - Diabetes Education required?>>
Gayndah - Podiatry: <<Gayndah - Podiatry required?>>
Gin Gin - Diabetes Education: <<Gin Gin - Diabetes Education required?>>
Gin Gin - Exercise Physiology: <<Gin Gin - Exercise Physiology required?>>
Gin Gin - Physiotherapy: <<Gin Gin - Physiotherapy required?>>
Monto - Diabetes Education: <<Monto - Diabetes Education required?>>
Monto - Dietition: <<Monto - Dietition required?>>
Monto - Exercise Physiology: <<Monto - Exercise Physiology required?>>
Monto - Podiatry: <<Monto - Podiatry required?>>
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Practice Details
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
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Referred by: <<Referred by>>
Name: <<Doctor:Name>>

Signature: ............................................   Date: ........................

OFFICE USE ONLY - Referral Entry: Date: ....................   UI: ....................

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Investigation Results (Selected):
<<Summary:Investigation Results (Selected)>>

Progress Notes (Selected):
<<Summary:Progress Notes (Selected)>>