REQUEST FOR PALLIATIVE CARE SERVICE
E-refer via ReferralNet (BH.PalliativeCare)
FAX:  03 4215 6390
		 							
GP Referral
		Referral Date: <TodaysDate>
Feedback Requested:  Yes

Referral to:
Barwon Health Palliative Care Service

Phone: 03 4215 5700
Fax: 03 4215 6390

Referral Urgency: <Referral Urgency>
		Referring General Practitioner:
Name:<DrName> 
Practice: <Practice> 
Address:<UsrAddress>
Phone: <UsrPhone>   
Fax:  <UsrFax>
Email: <DrEmail>
Provider No.: <DrProviderNo>	

Patient/Client/Consumer details:
Title: <PtTitle>
First name: <PtFirstName> 
Surname: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>   Age: <PtAge>
Sex at Birth: <PtSex>
Gender Identity: <GenderIdentity>
ATSI: <PtEthnicity>

Interpreter required: <Does the patient require an interpreter?>
Preferred language is: <If interpreter needed, which language>

Cultural safety requirements: <Cultural safety requirements?>
Access/Support requirements: <Access/Support requirements?>		Address: <PtAddress>
Mobile: <PtPhoneMob>
Email: <PtEmail>
Home Phone: <PtPhoneH>  
Work Phone: <PtPhoneWk>
Preferred method of communication: <Patient's preferred contact method>

Medicare: <PtMCNo> <PtMCLine> Expiry: <PtMCExpiry>
Pension/HCC: <PtPensionNo>
DVA: <PtDVANo>
Insurance: <PtInsFund> <PtInsNo>

NOK/Carer/Alternate contact:
Name: <NOKName>  Phone: <NOKContact>
Relationship: <NOKRelation>

	

Consent to referral: <Consent to referral>  
Consent to share information: <Consent to share information>
Is this a 2nd referral for the same problem: <Is this a 2nd referral for the same problem?>
Usual GP (if not referrer):  <Usual GP (if different to referrer)- Name/Practice>	

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<HealthPathways Barwon guidance in Ax Mx referral>	

Reason for referral:

<Reason for referral>

Primary Diagnosis:  <Primary Diagnosis>
Metatases, if any:  <Metastases, if any>
Current/Regular treatment: <Current/Regular treatment>  
Other services involved in care:  <Other services involved in care>

<Symptoms - tick any of the following that apply>
Pain? <Pain?>
Nausea? <Nausea?>
Constipation? <Constipation?>
Anxiety? <Anxiety?>
Depression? <Depression?>
Anorexia/Weight loss? <Anorexia/Weight loss?>
Shortness of breath? <Shortness of breath?>
Pyschosocial concerns? <Pyschosocial concerns?>
Comments: <Comments>

Does patient have ACP/Documented Goals of Care?  <ACP/Documented Goals of Care in place?>
Other specialist/s involved:  <Other Specialist/s involved>
Recent PHx Medication list review undertaken:  <Recent PHx Medication list review undertaken?>
GP available for home visits: <GP available for home visits?>	

Past Medical History:
<PMHActive>

Social History:
<SocialHx>

Family History:
<FamilyHx>

Current Medications:
<CurrentRx>

Alerts:
<Comment>

Allergies:
<Reactions>

Alcohol History:
<AlcHx>

Smoking Status:
<SmkStatus>
If smoker, smoking cessation discussed: <If smoker, smoking cessation discussed?>

Investigations/Results:
<Ix>

Electronically signed:  <DrName>