PULMONARY REHABILITATION REFERRAL
REFERRAL TO: Hervey Bay Physio (RA4655000X9)	
Name: <<Patient Demographics:Full Name>>	DOB: <<Patient Demographics:DOB>>	
Address: <<Patient Demographics:Full Address Preferred>>	Phone: <<Patient Demographics:Phone (Home)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	
Respiratory Diagnosis: <<Respiratory Diagnosis>>	
Other Medical Conditions: <<Clinical Details:History List>>
	
Relevant Investigations (e.g. CXR, LFTs, ABGs, other): <<Summary:Investigation Results (Selected)>>	
Medications:<<Clinical Details:Medication List>>	

Have you discussed pulmonary rehabilitation with patient? <<Have you discussed pulmonary rehabilitation w) pt?>>
Will transport be required?  <<Will transport be required?>>
Patient’s funding status: <<Patient's funding status>> <<If other please specify>>

Referring Health Professional
Name:<<Doctor:Name>>
Provider Number: <<Doctor:Provider Number>>	
Practice: <<Practice:Name>>
Phone:<<Practice:Phone>>				 Fax: <<Doctor:Fax>>
Date: <<Miscellaneous:Date (short)>>