OFFICIAL: Sensitive//Medical in confidence

	
SALHN GP PLUS BARIATRIC SURGERY PROGRAM REFERRAL

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

 Surname:  <PtSurname>

 Given Name: <PtFirstName>

Second Given Name: <PtMidName>

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

Referrals to be faxed to Fax: (08) 7425 8248	    
Enquiries can be directed to Phone: (08) 7425 8200 (opt 1) 	

REFERRAL CRITERIA FOR BARIATRIC SURGERY

	
  BMI > 35 with 2 or more comorbidities	
	
 BMI > 45 with 1 or more comorbidity	

	

	
  Aged 18-55 at time of referral	
	
  No alcohol or drug-dependency	

	

	
  Committed to program and making lifestyle changes	
	
  No unresolved psychiatric pathologies	

Comorbidities

  Diabetes (medication dependent)	
	
  Obstructive sleep apnoea	
	
  Hypertension	

	

	

	
  Ischemic heart disease	
	
  Arthritis	
	
  Liver Disease	

	

	

	
  Hyperlipidaemia	
	
  Impaired mobility	

	
	
SERVICE INFORMATION
	
There will be an initial appointment with the Nurse Consultant.  The expectation is that the investigation and optimisation of comorbidities particularly sleep apnoea, will continue to occur in primary care while your patient is on the waiting list.  Patients must attend a six month pre-surgical assessment program with the BMI clinic clinicians.	
	
REFERRAL URGENCY

	
  Urgent	
	
  Semi Urgent	
	
  Non Urgent	

	
REFERRER INFORMATION
	
Referrer’s name:	<DrName>	Provider Number (if applicable):	<DrProviderNo>	
Practice Name:
	<Practice>	Practice Phone:	<DrPhone>	
Practice address:	<DrAddress>
	
Referrer’s signature
(Electronically signed)	<DrName>	Date:	<TodaysDate>	
		
GENERAL PRACTITIONER DETAILS (if not referrer)
	
Doctor’s name:
	<DrName>	Surgery name:	<Practice>	
Surgery address:
	<DrAddress>	
Practice Phone:
	<DrPhone>	Practice Fax:	<DrFax>	
		
PATIENT DETAILS
	
Address:
	<PtAddress>	
Preferred phone:
	<PtPhoneMob>	Alternative phone:	<PtPhoneH>	
Medicare number:
	<PtMCNo>	Expiry date:	<PtMCExpiry>	

PATIENT DETAILS continued
	
Is the patient of 
Aboriginal or Torres Straight Islander origin?	<PtATSI>	
Is an interpreter 
required?	<Interpreter Required?>	Language:	<PtLanguage Spoken>	
Patient carer details (if relevant):		
		
BASELINE PATIENT DATA
	
Age (at time of referral):	<PtAge>	Weight:	<Weight>	
BMI (current):
	<BMI>	Height:	<Height>	
		
REFERRAL INFORMATION
	
Has the patient had previous bariatric surgery?
	<Previous Bariatric Surgery>	If yes, please specify date and health facility:

	
Has the patient had previous abdominal surgery?	<Previous Abdominal Surgery>	
Current medical conditions:
	<PMHActive>	
Current medications:
	<CurrentRx>

Any other relevant past medical history:
	<SelectedPMH>	
Allergies:
	<Reactions>	
Relevant social factors:
	<SocialHx>

Other relevant health professionals involved in the patient's care (including contact details):

	

		
Please attach Health Summary for assessment including sleep studies and recent blood tests.

OFFICIAL: Sensitive//Medical in confidence