Outpatient Appointment New Referral

		Enquiries: 9929 8500	Fax: 9929 8404		
Retain ORIGINAL for your own file. Fax to Outpatient Booking Unit on 9929 8404.					
	Referral Date:		
RVEEH must have patient phone number. 			
					
	Patient’s UR:		
						
PATIENT INFORMATION							
							
Title:	Surname:		Given Name:		
								
Date of birth:	Gender:	M / F					
								
Street:							
						
City:			Postcode:		
							
Home Number:	Work Number:		Mobile Number:		
							
Preferred Language:	Interpreter	Y / N	Asylum Seeker:   Y / N		
							
Medicare Number:	Position:		Expiry Date:		
							
Aboriginal / Torres Strait islander 	Y / N		TAC Number:		
								
DVA Number:	Expiry Date:						

Note: if your patient does not have a Medicare card they may not be able to attend the hospital’s outpatient clinics.

OUTPATIENT SPECIALTY (please tick):	□ Ear, Nose & Throat   or    □ Ophthalmology

CLINICAL REASON FOR REFERRAL

Symptoms:

Duration:

Functional impact:

Examination findings:

Is a diagnostic report requested in the  Referral Guidelines?  Y / N

Please dispatch relevant diagnostic reports, X-rays or pathology results relevant to this referral (please tick):

□ Audiogram   □ Optometrist Report   □ X-ray  □ CT Scan   □ MRI   □ Pathology   □ Other …...….....……………

The Eye & Ear Hospital is committed to protecting the privacy of every individual. We comply with legislation relating to privacy and confidentiality, including the Health Services Act1988 (Vic), Information Privacy Act 2000 (Vic), Freedom of Information 1982 (Vic) and the Health Records Act 2001 (Vic). The Hospital cannot use or disclose personal or health information without the consent of the individual, except if required or permitted under law.

RELEVANT PAST HISTORY & MEDICATIONS

DOCTOR’S DETAILS (or Doctor’s Stamp)		DOCTOR’S STAMP	
Surname:		Initial:			
Practice Name:					
Address					
City		Postcode:			
Phone		Fax:			
Email:					
Provider No				
Eye and Ear Referral 20140905