RURAL PRIMARY HEALTH SERVICE 
(RPHS) REFERRAL FORM
Please complete all sections and fax to (07) 4151 0794
or email: services@rhealth.com.au
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Patient details
Name: <<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: <<Is the patient 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
Asthma: <<Is the patient being referred for Asthma?>>
Arthritis: <<Is the patient being referred for Arthritis?>>
Cardio Vascular Disease: <<Is the patient being referred for CVD?>>
COPD: <<Is the patient being referred for COPD?>>
Obesity/Overweight: <<Is the patient being referred for Obesity?>>
Diabetes: <<Is the patient being referred for Diabetes?>>
Other: <<Other Reason for Referral>>
Medical Reason For Referral: <<Medical Reason for Referral>>
Individual: <<Individual Session?>>
Group (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?>>
Previous Medications/Surgical History: <<Previous Medications/Surgical History Attached?>>
Current Medications: <<Current Medications Information Attached?>>
Pathology Results: <<Pathology Results 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: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: ....................