REQUEST FOR ADVANCE CARE PLANNING SERVICES

Refer via Information & Access Service
ReferralNet: (BH CHRIAS)
Fax: 03 4215 7795
							
GP Referral
		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

Referral to:
Barwon Health Advance Care Planning Program

Ph: Information & Access: 03 4215 7700

Referral Urgency: Referral Urgency
Referral valid for: Referral valid for		Referring General Practitioner:
Name:Treating Doctor.Name
Practice: Practice.Name
Address:Practice.Address
Phone:  Practice.Phone
Fax:  Practice.Fax
Email: Treating Doctor.E-mail
Provider No.: Treating Doctor.Provider Number	

Patient/Client/Consumer details:
Title: Patient Demographics.Title
First name: Patient Demographics.First Name
Surname: Patient Demographics.Surname
Preferred Name: Patient Demographics.Popular Name

Date of Birth: Patient Demographics.DOB          Age: Patient Demographics.Age
Gender: Patient Demographics.Gender 

ATSI: Patient Demographics.ATSI Status
Interpreter required: Interpreter
Preferred language is: Preferred language
Please consider Telehealth for this patient: Telehealth 
Cultural safety requirements: Cultural Safety
Access/Support requirements: Access/Support		Address: Patient Demographics.Full Address
Mobile: Patient Demographics.Phone (Mobile)
Email: Patient Demographics.E-mail
Home Phone: Patient Demographics.Phone (Home)
Work Phone: Patient Demographics.Phone (Work)
Preferred method of communication: Preferred contact 

Medicare: Patient Demographics.Medicare Number  Expiry: Patient Demographics.Medicare Expiry Date
Pension/HCC: Patient Demographics.Pension Number
DVA: Patient Demographics.DVA Number
Insurance: Patient Demographics.Health Fund NamePatient Demographics.Health Fund Member Number

NOK/Carer/Alternate contact:
Name: Patient Demographics.NOK Name  
Phone: Patient Demographics.NOK Mobile Phone
Relationship: Patient Demographics.NOK Relationship

Consent to referral: Consent to referral
Consent to share information: Consent- information
Usual GP (if not referrer):  Usual GP

Consent to contact from ACP team: Consent to contact
Has client been given Advance Care Planning documents/information? ACP info provided

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
HealthPathways	

Diagnosis & reason for referral:
Diagnosis & referral

Other Service Involvement: 
Other Services

Past Medical History:
Clinical Details.Past History

Social History:
Clinical Details.Social History

Family History:
Clinical Details.Family History

Current Medications:
Clinical Details.Medication List

Alerts:
Clinical Details.Warnings

Allergies:
Clinical Details.Allergies

Alcohol History:
Clinical Details.Alcohol

Smoking Status:
Clinical Details.Smoking
If smoker, smoking cessation discussed: Smoking cessation

Electronically signed by: Treating Doctor.Name