Outpatient Appointment New Referral

Enquiries: 9929 8500        Fax: 9929 8404	
Retain ORIGINAL for your own file. Fax to Outpatient Booking Unit on 9929 8404.
RVEEH must have patient phone number.	Referral Date: <<Miscellaneous:Date (short)>> 
Patient's UR: <<Patient's UR: >>	

PATIENT INFORMATION
Title:	<<Patient Demographics:Title>>	Surname:	<<Patient Demographics:Surname>>	Given Name:	<<Patient Demographics:First Name>>	
Date of Birth:	<<Patient Demographics:DOB>>	Gender:	<<Patient Demographics:Gender>>			
Street:	<<Patient Demographics:Address Preferred Line 1>>, <<Patient Demographics:Address Line 2>>	
City:	<<Patient Demographics:Address Preferred City>>	Postcode:	<<Patient Demographics:Postcode>>	
Home Number:	<<Patient Demographics:Phone (Home)>>	Work Number:	<<Patient Demographics:Phone (Work)>>	Mobile Number:	<<Patient Demographics:Phone (Mobile)>>	
Preferred Language:	<<Patient Demographics:Language Preferred>>	Interpreter:	<<Interpreter>>	Asylum Seeker:	<<Asylum seeker>>	
Medicare Number:	<<Patient Demographics:Medicare Number>>	Position:		Expiry Date:	<<Patient Demographics:Medicare Expiry Date>>	
Aboriginal / Torres Strait islander:		Y / N 	<<Aboriginal / Torres Strait islander>>	TAC Number:	<<TAC Card Number>>	
DVA Number:	<<Patient Demographics:DVA Number>>	Expiry Date:	<<DVA 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 SPECIALITY: <<Outpatient Speciality >>

CLINICAL REASON FOR REFERRAL: 
	Symptoms: 	<<Reason for referral - symptoms: >>
	Duration: 	<<Reason for referral - symptom duration>>
	Functional Impact: 	<<Reason for referral - functional impact >>
	Examination findings:	<<Reason for referral - examination findings >>	

Is a diagnostic report requested in the referral guidelines? <<diagnostic report requested in referral guidelines?>> http://www.eyeandear.org.au/page/Health_Professionals/Referring_to_the_Eye_and_Ear/Referrals

Please dispatch relevant diagnostic reports, X-rays or pathology results relevant to this referral (please tick): 
o Audiogram 	o Optometrist Report	o X-ray	o CT Scan	o MRI	o Pathology	o 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: 
<<Clinical Details:History List>>
<<Clinical Details:Medication List>> 	

DOCTOR'S DETAILS (or Doctor's Stamp):	DOCTOR'S STAMP
Name:	<<Doctor:Name>>	Initial:			
Practice Name:	<<Practice:Name>>		
Address:	<<Doctor:Address>>		
City:	<<Doctor:City>>	Poscode:	<<Doctor:Postcode>>		
Phone:	<<Doctor:Phone>>	Fax:	<<Doctor:Fax>>		
Email:	<<Doctor:E-mail>>		
Provider No:	<<Doctor:Provider Number>>