Respiratory Clinic Referral Form

For ONLINE booking please visit: https://www.hotdoc.com.au

Available	Location	Address	Phone	Fax:
Open Now Mon - Fri 12:30pm - 4:30pm	Bathurst	Ochre Health Bathurst Building 1470 CSU, Panorama Ave	02 6331 9444	02 6332 1962
Open Mon & Fri 9am - 1pm Wed 1pm - 5pm	Broken Hill	RFDSSE Hangar 1, Airport Rd, Broken Hill	0447 815 383 or 08 8080 3780	08 8088 1534
Open Now Mon - Wed 9am - 1pm Thurs 1pm - 5pm	Cobar	Cobar Primary Health Care Centre 24 Harcourt Street, Cobar	02 6836 5000	02 6836 1274
Open 8:30am - 12:30pm	Cowra	Cowra Medical Associates 165 - 169 Kendal Street, Cowra	02 6341 1400	02 6341 1400
Open Now Mon - Fri 8:30am - 1pm 2:00pm - 5pm	Dubbo	Dubbo Medical & Allied Health Group 183 Brisbane Street, Dubbo	02 6815 9900 Option 1	02 6884 4176
Opens 13th May Mon - Sun 9am - 1pm	Mudgee	South Mudgee Surgery 11 Nicholson Street	0417 072 652	02 6372 6617
Open 8am - 12pm 1pm to 5pm	Orange	Bloomfield Medical Group 1521 Forest Rd, Orange	02 5335 6666	02 5335 6688

PATIENT DETAILS Patient Name: <<Patient Demographics:Full Name>> Previous Name: Medicare No: <<Patient Demographics:Medicare Number>> DOB: <<Patient Demographics:DOB>> Gender: <<Patient Demographics:Gender>> Address: <<Patient Demographics:Full Address>> Phone (h): <<Patient Demographics:Phone (Home)>> Mobile: <<Patient Demographics:Phone (Mobile)>> Alternate Contact:	Referrers Name: <<Doctor:Name>> Provider No: <<Doctor:Provider Number>> Practice Address: <<Doctor:Full Address>> Phone: <<Doctor:Phone>> Fax: <<Doctor:Fax>> Usual GP if not referrer: <<Usual GP if not referrer:>> Date of Referral: <<Miscellaneous:Date>> Reason for Referral: Consideration of COVID-19 screening test

Referral Details: Pre-referral information available at: Western NSW PHN website https://www.wnswphn.org.au/coronavirus/gp_information
Refer to latest COVID-19 alert (faxstream) 1) https://www.nsw.gov.au/covid-19 If your patient meets the COVID-19 testing criteria, does the patient have: A fever (or history of fever) OR acute respiratory infection? <<Does pt have fever or acute Resp Infection?>> FOR PATIENTS WHO HAVE MODERATE-SEVERE ILLNESS AND REQUIRE HOSPITAL ASSESSMENT. PLEASE REFER TO YOUR LOCAL EMERGENCY DEPARTMENT AFTER RINGING THE ED MOIC. FOR PATIENTS WHO DO NOT MEET THE CURRENT TESTING CRITERA DO NOT REFER TO THE RESPIRATORY CLNIC FOR TESTING.
Signed: Date: <TodaysDate>
Interpreter required: <<Patient Demographics:Requires Interpreter>> Language: <<Patient Demographics:Language Spoken>>
Allergies: <<Clinical Details:Allergies/Adverse Reactions>>
Past Medical History: <<Clinical Details:History List>>
Current Medications: <<Clinical Details:Medication List>>
Relevant Social, Family or Occupational History: <<Clinical Details:Family History>> <<Clinical Details:Social History>>
Interpreter Required: <<Patient Demographics:Requires Interpreter>> Language: <<Patient Demographics:Language Spoken>>
Investigations: <<Summary:Investigation Results (Selected)>>