Focus Healthcare: Online Referral

Online Referral

This is a secure page. To ensure privacy all information is encrypted during transfer

General Information
*Gender
*Title	Mr Mrs Ms
*Surname
*First Name
Date of Birth
*Phone
If Child, Name of Guardian
Date of Referral
Referral Source
Date of First Contact
Interpreter Required?	Yes No

Visit Information
*Visit Address		*First Contact Person:
*Suburb		*Visit Request Date
Postcode		*Visit Request Time

Hospital Referrals
Hospital UR
Consultant
Ward
Discharge Date
Next OPD Date
Allergy/Alert/ADR
GP Name
GP Phone Number
GP Provider Number
Medication Authorisation Organised?	Yes No
Able to attend Clinic?	Yes No
Does Client have a carer?	Yes No
Carer Gender

Has the Client any of the Following		Complete if known
Pension Card	Yes No	Medicare Number
Health Care Card	Yes No	DVA File Number
DVA Entitlement	Yes No	DVA Card Colour
Private Insurance	Yes No	Fund Name
Workers Compensation	Yes No	Membership Number
Accident	Yes No	Insurer
Medical Diagnosis
Surgical Intervention
Please identify services required from Focus Healthcare

Nursing Care requested
Home Support Services requested
Occupational Therapy Services requested
Personal Emergency Monitoring requested
*Name of person completing this form
*Email address of person completing this form
Any other information pertaining to this client. List foreseeable hazards to our nurses or other agencies (eg. dogs, smoking. harassing, aggressive behaviour)

To make a referral simply telephone 1300 363 262
For information on other services visit our web site www.focushealthcare.net.au
Focus Healthcare: striving for service excellence