OFFICIAL: Sensitive//Medical in confidence

	
SALHN RESPIRATORY
REFERRAL
OUT OF HOSPITAL SERVICES	

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

Surname:       <<Patient Demographics:Surname>>

Given Name:  <<Patient Demographics:First Name>>

Second Given Name:   <<Patient Demographics:Middle Name>>

  D.O.B: <<Patient Demographics:DOB>>   Sex/Gender <<Patient Demographics:Gender>>	

Referrals can be faxed to  Fax: (08) 8164 9199            Enquiries can be directed to Phone: (08) 8164 9853

(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:
	<<Patient Demographics:Address>>	
Preferred phone:
	<<Patient Demographics:Phone (Mobile)>>	Alternative phone:	<<Patient Demographics:Phone (Home)>>	
Medicare number:
	<<Patient Demographics:Medicare Number>>	Expiry date:	<<Patient Demographics:Medicare Expiry Date>>	
Is the patient of 
Aboriginal or Torres Straight Islander origin?	<<Patient Demographics:ATSI>>	
		
REFERRER INFORMATION	
Referrer’s Name:
	<<Miscellaneous:Current User>>	Position/Discipline:	<<Doctor:Provider Number>>	
Practice/Organisation Name:
	<<Practice:Name>>	Practice Phone :	<<Practice:Phone>>	
Email Address:
	<<Practice/Location:E-mail>>	Date:	<<Miscellaneous:Date>>	

REFERRAL INFORMATION	
Primary Diagnosis:
		
Relevant past medical history:
	<<Clinical Details:History List>>	
Allergies:

	<<Clinical Details:Allergies/Adverse Reactions>>	
Current medications:

	<<Clinical Details:Medication List>>	
Referral request / presenting problem

	(Situation / background / assessment and recommendations)

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