SPECIALIST PALLIATIVE CARE RURAL TELEHEALTH REFERRAL FORM
fax to: (07) 5470 5243

PATIENT DETAILS:
URN (if known): 
Family Name: <<Patient Demographics:Surname>>
Given Names: <<Patient Demographics:First Name>> <<Patient Demographics:Middle Name>>
Address: <<Patient Demographics:Address>>
Date of Birth: <<Patient Demographics:DOB>>
Sex: <<Patient Demographics:Gender>>
Phone - Home: <<Patient Demographics:Phone (Home)>> Work: <<Patient Demographics:Phone (Work)>> Mobile: <<Patient Demographics:Phone (Mobile)>>

REFERRAL DETAILS:
Referral to: <<Referral to>> - <<Other Dr (if applicable)>>

Referral for:
Introduction to palliative approach: <<Referral for - Introduction to palliative approach>>
Symptom management: <<Referral for - Symptom management>>
MASS Support: <<Referral for - MASS Support>>
Advance Care Planning: <<Referral for - Advance Care Planning>>
Psycosocial needs: <<Referral for - Psychosocial needs>>
Terminal care: <<Referral for - Terminal care>>

Referral Type: <<Referral Type>>
Estimated Prognosis: <<Estimated Prognosis>>
Are the patient and family aware of this referral, their condition, and their diagnosis? <<Patient/family aware of referral/condition/diagnosis>>

Primary malignant diagnosis (principal life-limiting illness)
Malignant: <<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 disease process in comments section below)
<<Primary non-malignant diagnosis>>
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:
Name of GP: <<Doctor:Name>> Contact Phone: <<Doctor:Phone>>
Practice name: <<Practice:Name>>
Primary contact to arrange appointment: <<Primary contact to arrange appointment>>
Primary Contact Phone: <<Primary Contact Phone>> Email: <<Email>>

Mobile phone or internet coverage: (for TELEHEALTH CONSULTATION)
Smart device available: <<Smart device available>>
Internet connection: <<Internet connection>>

GP: <<Doctor:Name>> Provider Number: <<Doctor:Provider Number>> Date: <<Miscellaneous:Date (short)>>