Outpatient Appointment New Referral
Enquiries: 9929 8500
Retain ORIGINAL for your own file. Fax to Outpatient Booking Unit on 9929 8404.
RVEEH must have patient phone number. Appointment details will be mailed to the patient.
Fax: 9929 8404
<TodaysDate>
Referral Date:
Patient’s UR:
PATIENT INFORMATION
Name: <PtFullName>
Date of birth:
<PtDoB>
Address:
<PtAddress>
Home Number:
<PtPhoneH>
Age:
Work Number:
<PtAge>
Gender:
<PtPhoneWk>
Mobile Number:
<PtPhoneMob>
<Interpreter
required?>
Asylum Seeker:
Y/N
Preferred Language:
<Preferred
language>
Interpreter
Medicare Number:
<PtMCNo>
Position:
Expiry Date:
Expiry Date:
TAC Number:
Pension Number:
<PtPensionNo>
Health Care Card No.:
<PtSex>
<PtMCExpiry>
Expiry Date:
DVA Number: <PtDVANo>
Expiry Date:
Card Type:
Note: if your patient does not have a Medicare card they may not be able to attend the hospital’s outpatient clinics.
OUTPATIENT SPECIALTY:
<PtDVACard>
<Outpatient speciality>
CLINICAL REASON FOR REFERRAL
Symptoms:
Duration:
Functional impact:
Examination findings:
<Ix>
Is a diagnostic report requested in the Referral Guidlines? Y / N
Please dispatch relevant diagnostic reports, X-rays or pathology results relevant to this referral (please tick):
□ Audiogram
□ Optometrist Report □ X-ray □ CT Scan □ MRI □ Pathology □ Other …...….....……………
The Eye & Ear Hospital is committed to protecting the privacy of every individual. We comply with legislation relating to privacy and
confidentiality, including the Health Services Act1988 (Vic), Information Privacy Act 2000 (Vic), Freedom of Information 1982 (Vic) and the
Health Records Act 2001 (Vic). The Hospital cannot use or disclose personal or health information without the consent of the individual,
except if required or permitted under law.
RELEVANT PAST HISTORY & MEDICATIONS
<PMHAll>
<CurrentRx>
DOCTOR’S DETAILS (or Doctor’s Stamp)
Name:
Practice Name:
Address
Phone
Provider No
DOCTOR’S STAMP
<DrName>
<Practice>
<UsrAddress>
<UsrPhone>
<DrProviderNo>
RVEEH Referral Best Practice 20130712.rtf
Fax:
<<UsrFax>