REQUEST FOR AUDIOLOGY APPOINTMENT	
Allied Health Dept- Level 2, University Hospital Geelong

FAX: 03 4215 0833  (No ReferralNet)  
							
GP Referral
		Referral Date: Miscellaneous.Date
Feedback Requested:  Feedback requested

Referral to:
Barwon Health Audiology Services
Ph: 03 4215 0827
Fax: 03 4215 0833

Service requested:
Service requested

Referral Urgency: Referral Urgency		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

Additional contact/support person:
Additional contact/s

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

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

Relevant clinical details/reason for referral:
Clinic details

Please indicate if patient suffers from any of the following: Conditions
Visual Impairment: Visual Impairment
Neck issues: Neck issues
Previous middle ear surgery: Prev. middle ear Sx
Falls in last 12 months (please indicate number):  Recent falls
Recent MRI brain/ CT scan:  Recent MRI brain/ CT     Date completed: Date completed

Past Medical History:
Clinical Details.Past History

Current Medications:
Clinical Details.Medication List

Alerts:
Clinical Details.Warnings

Allergies:
Clinical Details.Allergies

Investigations/Results:
Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name