Outreach Allied Health Service - Referral Form
Please Send Via Fax
16 Ryan St
Belgian Gardens
QLD 4810
PO Box 612
Belgian Gardens
QLD 4810
Fax: 07 4421 7455
Phone: 07 4722 8766
Referral Details:
Name: ____________________________________________ Phone: _________________________ Fax: ___________________________
Organisation/Address: _____________________________________________ Referrers Signature: _________________________________
Patient gives consent for the referral and sharing of medical information:
(Mandatory)
CLINICIAN & CORRESPONDING AREA OF SERVICE
Occupational Therapist
Dietitian
Exercise Physiologist
Diabetes Educator
Podiatrist
Hughenden
Ayr
Ayr
Ayr
Hughenden
Richmond
Bowen
Cardwell
Bowen
Richmond
Cannonvale
Charters Towers
Cardwell
Cardwell
Hughenden
Charters Towers
Charters Towers
Ingham
Clermont
Collinsville
Richmond
Collinsville
Hughenden
Townsville
Dysart
Ingham
HEAL
(Group Lifestyle Modification Program)
Proserpine
Richmond
Sarina
Home Hill
Hughenden
Ingham
Moranbah
Ayr
Middlemount
Bowen
Richmond
Charters Towers
Hughenden
Ingham
Mackay
Richmond
Sarina
Townsville
Client Details
Title:
Mr
Mrs
Ms
Master
Miss
Given Name: _____________________________________________ Surname:
Address: ___________________________________________________________________________________________________________
IF YOU DO NOT WISH US TO LEAVE A MESSAGE/OR TEXT YOU ON THIS NUMBER, PLEASE MAKE THAT CLEAR
Phone: (Home) __________________________ (Mobile) ___________________________ Best time to contact: ________________________
Medicare No: ___________________________ Expiry Date: ________________________ Ref No: ___________________________________
Date of Birth: ___________________________
Does the patient identify as
Aboriginal
Male
Female
Torres Strait Islander
Other
No
If we are unable to contact you directly to confirm or reschedule your appointment, please indicate below, who you give permission
for us to speak with:
Emergency Contact: (Name) ___________________________ (Phone) _______________________ (Other) ___________________________
Special Needs:______________________________________________________________________________________________________
Reason for Referral: (Mandatory) ______________________________________________________________________________________
Regular GP Details: (Name) ______________________________ (Practice) ___________________________________________________
GP Phone: _________________________________________________ GP Fax: ________________________________________________
Medical History:
Kidney Disease
Cancer
Heart Disease/CVD
Diabetes
Respiratory Disease/COPD
Liver Disease
Other
Medications: (Please attach if necessary) _____________________________________________________________________________________
Relevant pathology and biochemistry attached: