REFERRAL
CPCT	(Please complete or affix Addressograph Label here)
MRN: <<Patient Demographics:Medicare Number>>    DOB: <<Patient Demographics:DOB>>
Surname: <<Patient Demographics:Surname>>
Given Names: <<Patient Demographics:First Name>>	
Please return completed form to PO Box 261, Kogarah, 1485 or Fax 9588 1635 
This Information is essential for proper assessment on admission.  Thank You for completing all questions.	
Principal Diagnosis:________________________________________________________________
Date of Diagnosis: _________________________________________________________________
Problems leading to Referral:_________________________________________________________
________________________________________________________________________________
Other Medical Problems: ____________________________________________________________
________________________________________________________________________________
Allergies:_________________________________________________________________________
Other Specialists Involved:___________________________________________________________
________________________________________________________________________________
	
Relevant Treatment:
Surgery:  _______________________________________________ Date:_____________________
Surgeon:  ______________________________________________ Location:__________________
Weight Bearing Status: _____________________________________________________________
Chemotherapy:  r  Yes  r  No  Location: ______________  Doctor:_____________  Date:  ______
Radiotherapy:   r   Yes  r  No  Location: ______________  Doctor: _____________  Date: ______	
Investigations & Results:  (Please enclose or transmit copies of relevant reports / results / etc)	

Current Medications & Dose	

	

	

	

	

	

	
Social Information: _________________________________________________________________
Patients Knowledge of Present Condition: ______________________________________________
Activities of Daily Living: ____________________________________________________________
Family/Carer Information: ___________________________________________________________
________________________________________________________________________________
Services Involved in Care: ___________________________________________________________
________________________________________________________________________________

Referring Doctor: <<Doctor:Name>>
Address: <<Doctor:Address>>
Phone: <<Doctor:Phone>> Fax: <<Doctor:Fax>>
Signature: ____________________Date: _____________
Provider: <<Doctor:Provider Number>>	
Referring Doctor: ________________________________
Address: _______________________________________
Phone: ______________________ Fax: ______________
Signature: ____________________Date: _____________
Provider  _______________________________________