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
Referral Date:
Patient’s UR:
<<Miscellaneo
us:Date>>
<<UR No. if
known>>
PATIENT INFORMATION
Name: <<Patient Demographics:Full Name>>
Date of birth:
Address:
<<Patient
Age: <<Patient
Demographics:D
Demographics:Age
OB>>
>>
<<Patient Demographics:Full Address>>
Home Number:
<<Patient
Demographics:P
hone (Home)>>
Work Number:
Preferred Language:
<<Preferred
language>>
<<Patient
Demographics:M
edicare
Number>>
<<Patient
Demographics:P
ension
Number>>
Interpreter
Medicare Number:
Pension Number:
Health Care Card No.:
DVA Number:
Gender:
<<Patient
Demographics:
Sex>>
<<Patient
Demographics:Pho
ne (Work)>>
Mobile Number:
<<Interpreter
required?>>
Asylum Seeker:
<<Patient
Demographics:
Phone
(Mobile)>>
Y/N
Position:
Expiry Date:
Expiry Date:
TAC Number:
Expiry Date:
<<Patient
Demographics:D
VA Number>>
Expiry Date:
Note: if your patient does not have a Medicare card they may not be able to attend the hospital’s outpatient clinics.
OUTPATIENT SPECIALTY:
<<Outpatient speciality>>
CLINICAL REASON FOR REFERRAL
Reason:
Include symptoms, duration and functional impact
<<Clinical reason for referral>>
Examination findings:
<<Summary:Investigation Results (Selected)>>
Is a diagnostic report requested in the Referral Guidelines? 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
<<Clinical Details:Medication List>>
RVEEH Referral Medical Director 20130625.rtf
DOCTOR’S DETAILS (or Doctor’s Stamp)
Full Details:
Practice Name:
Email:
<<Doctor:Full Details>>
<<Practice:Name>>
<<Doctor:E-mail>>
DOCTOR’S STAMP