SPECIALIST PALLIATIVE CARE RURAL TELEHEALTH REFERRAL FORM
fax to: (07) 5470 5243
PATIENT DETAILS:
URN: <URN (if known)>
Family Name: <PtSurname> 
Given Names: <PtFirstName> <PtMidName>
Address: <PtAddress>
Date of Birth: <PtDoB>   Sex: <PtSex>
Telephone - Home:<PtPhoneH> Mob:<PtPhoneMob> Work:<PtPhoneWk>

REFERRAL DETAILS
Referral to: <Referral to>  -  <Other Dr (if applicable)>
Referral for: <Referral for>
Referral Type: <Referral Type>
Estimated Prognosis: <Estimated Prognosis>
Are the patient and family aware of this referral, their condition, and their diagnosis? <Are the patient and family aware of this referral, their condition, and their diagnosis?>

Primary Malignant diagnosis (principal life-limiting illness)
Malignant: <Primary malignant diagnosis (principal life-limiting illness) - Malignant?>
Primary site and date of diagnosis: <Primary site and date of diagnosis>
Site of metastatic disease: <Site of metastatic disease>

Primary non-malignant diagnosis (please complete actual diagnosis in comments section below)
<Primary non-malignant diagnosis (please complete actual disease process in comments section below)>

Clinical Issues / significant comorbidities
<Clinical issues / significant comorbidities>

Advance Care Planning
Advance Health Directive completed: <Advance Health Directive completed>
Statement of Choices completed: <Statement of Choices completed>
Enduring Power of Attorney completed: <Enduring Power of Attorney completed>
Acute Resuscitation Plan completed: <Acute Resuscitation Plan completed>

Referral received from: (please complete relevant field)
Name of GP: <UsrName>
Contact Phone: <UsrPhone>
Practice name: <Practice>
Primary contact to arrange appointment: <Primary contact to arrange appointment>
Primary Contact Phone: <Primary Contact Phone> Email: <Email>
Planned Telehealth Consultation: <Planned Telehealth Consultation>

Mobile phone or Internet coverage: (for TELEHEALTH CONSULTATION)
<Mobile phone or Internet Coverage: (for TELEHEALTH CONSULTATION)>

Complete if applicable:
Community Nursing Service - Contact Phone: <Community nursing service contact phone (if applicable)>  Email: <Email>

Signed: <DrFirstName> <DrSurname> Provider no.: <DrProviderNo>  Date: <TodaysDate>