REQUEST FOR OUTPATIENT APPOINTMENT
South Australian Intellectual Disability Health Service (SAIDHS)
Ingle Farm Recreation Centre
1/58 Beovich Rd
Ingle Farm 5098
South Australia
Ph: 8257 7300
Fax: 8257 7399
Email: HealthSAIDHS@sa.gov.au
Please note, SAIDHS is a consultation service model and unable to provide ongoing care, case management or emergency/crisis services.

REFERRER INFORMATION
Date of Referral | Miscellaneous.Date
Referrer Name | Treating Doctor.Name
Provider Number | Treating Doctor.Provider Number
Practice Name | Practice.Name
Practice Address | Practice.Address
Practice Telephone | Practice.Phone
Practice Fax | Practice.Fax
Email | Treating Doctor.E-mail

PATIENT DETAILS
Name | Patient Demographics.Full Name
Address | Patient Demographics.Full Address

Residence Type

Residence Type
Agency details: Agency details
If other, please specify: Specify other

Phone

Home: Patient Demographics.Phone (Home) 
Mobile:Patient Demographics.Phone (Mobile)

Date of birth | Patient Demographics.DOB
Gender | Patient Demographics.Gender
Aboriginal and/or Torres Strait Islander | Patient Demographics.ATSI Status

DVA / Medicare no.

DVA:Patient Demographics.DVA Number
Medicare no: Patient Demographics.Medicare Number

Medicare expiry date | Patient Demographics.Medicare Expiry Date
Interpreter required | Interpreter Required

Key Contact

Name: Patient Demographics.Emergency Contact Name
Relationship to patient: 
Phone: Patient Demographics.Emergency Contact Mobile Phone
Email:

Patient consent

Self-consenting: Self consenting
Legal Guardian: Legal Guardian
OPA: OPA
Name of consenting person: Name of Consenting
Phone number of consenting person: Phone No of Consent

REFERRAL DETAILS
Presenting condition(s) or issue(s) | Presenting condition

Reason for referral
Select one or more as appropriate

Establish diagnosis: Reason for Referral
Advice: Reason for Referral 
Assessment and management plan: Reason for Referral
Reassurance for patient and/or family:Reason for Referral
Second opinion: Reason for Referral
Other:Reason for Referral
If other, please specify:Reason for Referral

Eligibility criteria
Select one or more as appropriate

Intellectual disability: Eligibility Criteria
Significant developmental disability: Eligibility Criteria
and
Autism spectrum disorder: Eligibility Criteria
Mental illness or suspected mental illness: Eligibility Criteria
Severe or profound communication and/or behavioural issues:Eligibility Criteria
Other co-morbidities: Eligibility Criteria
Other complexities or issues which have not been able to be: managed in mainstream services: Eligibility Criteria

Relevant clinical history and/or
examinations

Clinical Details.Past History

Current medications | Clinical Details.Medications - Current PRN
Results of recent investigations | Clinical Details.Result List (Selected)
Allergies | Clinical Details.Allergies
Relevant social history | Clinical Details.Social History
Other considerations and patient requirements (e.g. visually impaired, literacy level) | Other considerations

Relevant health professionals
and contact details

Relevant health prof

REGULAR GP INFORMATION (if not referrer)
Doctor Name |
Practice Name |
Practice Address |
Practice Telephone |