OFFICIAL: Sensitive//Medical in confidence

	
SALHN RESPIRATORY
REFERRAL
OUT OF HOSPITAL SERVICES	

Facility/Site: ……………………………………………………....	
 
SA Health UR No: ..............................................………….....

Surname:       <PtSurname>

Given Name:  <PtFirstName>

Second Given Name: <PtMidName>  

  D.O.B: <PtDoB>    Sex/Gender <PtSex>	

Referrals can be faxed to  Fax: (08) 8164 9199            Enquiries can be directed to Phone: (08) 8164 9583

(for HERRO and Pulmonary Rehabilitation please complete referral form available on the Intranet)	

SERVICE REQUESTED	

   Airway Clearance	
	
   Respiratory Physiotherapy (Neuromuscular)	

	

	
   Respiratory Nurse	
	
   Speech Pathology	

	
	
PATIENT DETAILS	
Address:
	<PtStreet>	
Preferred phone:
	<PtPhoneMob>	Alternative phone:	<PtPhoneH>	
Medicare number:
	<PtMCNo>	Expiry date:	<PtMCExpiry>	
Is the patient of 
Aboriginal or Torres Straight Islander origin?	<PtATSI>	
		
REFERRER INFORMATION	
Referrer’s Name:
	<UsrName>	Position/Discipline:	<DrProviderNo>	
Practice/Organisation Name:
	<Practice>	Practice Phone :	<LocationPhone>	
Email Address:
	<LocationEmail>	Date:	<TodaysDate>	

REFERRAL INFORMATION	
Primary Diagnosis:
		
Relevant past medical history:
	<PMHActive>	
Allergies:

	<Reactions>	
Current medications:

	<CurrentRx>	
Referral request / presenting problem

	<VisitReason>

	
Please attach any relevant results (PFTs, imaging), medication lists, discharge summaries and/or clinic correspondence
OFFICIAL: Sensitive//Medical in confidence