Registration, Referral and Booking form for VFPMS Patients
WARNING: PLEASE COMPLETE ALL FIELDS, otherwise this sheet will be returned to you
Patient ID Label, or
Southern Health UR
Office use:
____________________ and / or RCH UR _______________________
VFPMS UR number from
IBA (if Southern Health
patient)
Patient name _________________________________________
Address _____________________________________________
_____________________________________ P’code_________
Phone
_________________
_________________________________________

Date of Birth ______________________ Sex: male

female
Parent / Caregiver / DHS worker details
Contact 1
Contact 2
Name
Name
__________________________________
__________________________________
Relationship _____________________________
Relationship _____________________________
Address (if different to patient’s address)
Address (if different to patient’s address)
__________________________________________
__________________________________________
______________________
______________________
Phone
Post Code ________
__________________________________
Phone
Post Code ________
__________________________________
IBA Referral to the VFPMS
Referral Date:
Date & Time of Request for Examination: ___________________________
(If Date is the same as Referral Date, write Time only)
Examination Date & Time: (if same as Requested, write a.a.) ______________________
Protective Services Inv.:
Priority:
Urgent

Reason for Referral:
= (within 2 hrs) 
Semi Urgent = (within 24hrs) 
Sexual Abuse
 (Problem 1)
Physical Abuse
 (Problem 2)
Police Involved:

Referral to Counselling made:
Next Available

Neglect/Child at Risk  (Problem 3)
Yes 
No 
No Further Action

Emotional / Other  (Problem 4)
Date Medical Report Completed:
__________________________
Referral Source: (Please choose from the list on the reverse & write here)
Appointment details
Doctor:
Campus:
Appointment:
RCH


MMC
Outcome:

Date
_________________
New
Time
_________________
Ext. new = 1½ hrs
Ward Assessment? Yes 
No 
= 1 hr
The patient:
Attended Yes 
No 

Follow-up appt made
(give details):
Review
= ½ hr

Ext. r/v
= 1 hr


Encounter details (i.e. Episodes of Care in IBA)
Date
Indirect activity:
(see reverse side of
this page for
definitions)
Case Conference
Court
Investigative Work
inc Case R/v
( if inpatient &
note if attended a
SCAN meeting)
P.T.O.
116095814
Secondary consult
Telephone Advice
Date
Date
Date
Date
Date
Date
Date
Date
Referral Source: Please circle
OR write in space allocated on previous page.
This list is a mixture of RCH departments and external agencies that is available in IBA.
For Monash patients, choose best fit.
The Referral Sources you are most likely to use have been placed at the top of the list.
If you have received a referral from the wards, choose Inpatient.
** Only choose GACE or CASA if it became apparent during counselling that the patient required a
medical.
 Please do not choose those categories that have a strikethrough.





CASA **
DHS - Child Protect.
Emergency
Family-Parent/Carer
Gatehouse Centre **
General Practitioner
Intensive Care Unit
Inpatient (not ICU)
Other Hospital
Paediatrician (community)
Police
Self
Other
Adolescent Health
Adolescent Medicine
Allergy
Audiology
Burns
Cardiac
Cardiac Surg
CCHAP
CD&R
Cerebral Palsy
Children’s Cancer Centre
Community Agencies
Community Nurses
Day Med Centre
Dental Health Serv.
Dentistry
Dept Human Services
Dermatology
Diabetes
Ear/Nose/Throat
Emergency Rooms
Encopresis
Endocrine
Eye
Gastroenterology
General Dentist
General Medical
General Surgery
Genetic
Haematology/Oncology
Hand
Immunology CSL
Interpreter
Limb Deficiency
M&CH Nurse
Major Practitioner
Maternity Hospitals
Mental Health
Neonates
Neurology
Neurosurgical
Nutrition-Dietetics
Obesity
Occupational Therapy
Oral/Maxillo
Orthopaedic
Orthotics/Prosthetic
Physiotherapy
Plastic Surgery
Private Rooms
Psy - Psychiatry
Radiology
RCH Consultant
Rehabilitation Dept
Renal
Renal Transplant
Respiratory Medicine
School Med Service
School-primary/secon
Seizure Dis
Social Work
Specialist
Speech Pathology
Spina Bifida
Uncle Bob's Centre
VFPMS
Vic Infant Programme
Wheelchair
Indirect activity:
Definitions
Case Conference
Includes SCAN meetings.
Court
Equals court attendance, even if evidence not given on the day.
Investigative Work inc Includes preparation for court, review of results & collection of additional
Case Review
information.
Secondary Consult
Sought from or provided to health professionals in relation to an individual patient.
Telephone Advice
(Excludes Secondary Consult). Includes advice to Child Protection & Police.
 Please indicate if any of these encounters are performed when the child is an inpatient. If entering
data directly into IBA, please note in the EOC Comments box that the child was an inpatient and if
you attended a SCAN meeting.
When complete, please fax to
116095814
Helen Shields
Joanne Dean
03 9594 6004
03 9345 6543
(MMC) or
(RCH)