PULMONARY REHABILITATION REFERRAL
REFERRAL TO: Hervey Bay Physio (RA4655000X9)	
Name: <PtFullName>	DOB: <PtDoB>	
Address: <PtAddress>	Phone: <PtPhoneH>
Mobile: <PtPhoneMob>	
Respiratory Diagnosis: <Respiratory Diagnosis>	
Other Medical Conditions: <SelectedPMH>

	
Relevant Investigations (e.g. CXR, LFTs, ABGs, other): 
<Ix>	
Medications:
<CurrentRx>	

Have you discussed pulmonary rehabilitation with patient? <Have you discussed pulmonary rehabilitation with patient?>
Will transport be required?  <Will transport be required?>
Patient’s funding status: <Patient Funding Status> <Patient Funding Status - Other. Please Specify>

Referring Health Professional
Name: <UsrName>
Provider Number: <DrProviderNo>	
Practice: <Practice>		
Phone: <UsrPhone>
Fax: <UsrFax>