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)>>