REQUEST FOR COGNITIVE,  DEMENTIA & MEMORY SERVICE (MEMORY CLINIC)
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 Cognitive, Dementia & Memory Service (Dr Adrian Low)
Ph: 03 4215 5411 (Memory Clinic)

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
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
Statewide Referral Criteria apply for Specialist Clinics Referrals. 
Referral criteria	

Reason for referral:
Reason for referral

Onset of cognitive/behaviour change:
Cognitive change

Impact of cognitive change on client function (include any safety risks):
Impact to function

MMSE score:  MMSE score           Date completed: Date completed

Current care details (eg other services):
Current care details

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

Investigations/Results (Please ensure all below are included for referral to be accepted)

FBE: FBE
ESR: ESR
U&Es: U&Es
CT Brain: CT Brain

	LFTs: LFTs
TSH: TSH
MSU: MSU	Gluc: Glucose
Ca: Ca
Vit B12: Vit B12	RBC Folate: RBC folate
Syphilis serology: Syphilis serology	

Clinical Details.Result List (Selected)

Electronically signed by: Treating Doctor.Name