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
Name: <PtFullName> 
DOB: <PtDoB>
Address: <PtAddress>
Phone: <PtPhoneH>  Mobile: <PtPhoneMob>
Gender: <PtSex>
Patient identifies as: <Patient identifies as>
CALD: <Patient is culturally and linguistically diverse (CALD)?>
Does the Patient have a:
Active My Health Record?: <Active My Health Record?>
Current Health Care Card?: <Current Health Care Card?>
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Mandatory
Patients living in RA 3-5 Areas with Chronic Disease, or risk of diagnosis. Current Health Care Card.

Chronic Disease Patient being referred for: <Chronic Disease Patient being referred for (Please select all that apply)>
Other Chronic Disease (if applicable): <Other Chronic Disease (if applicable)>
Medical Reason for Referral: <Medical Reason for Referral>
Individual Session: <Individual Session>
Group Session (Exercise Physiology - Gin Gin only): <Group Session - (Exercise Physiology - Gin Gin only)>
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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? (incl. HbA1c, Lipids, Urine Albumin, renal and liver function tests)>
Previous Medications/Surgical History: <Previous Medications/Surgical History attached?>
Current Medications: <Current Medications attached?>
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Allied Health Service (please indicate 'Y' or tick for all appropriate services required)
Location	Diabetes Educator	Dietitian	Exercise Physiology	Physiotherapy	Podiatry	
Biggenden						
Eidsvold						
Gayndah						
Gin Gin						
Monto						
Mundubbera						
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Practice Details
<Practice>
<UsrAddress>
Phone: <UsrPhone>   Fax: <UsrFax>
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Referred by: <Referred by>
Name: <DrName>

Signature: _______________________   Date: ___________

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