GP Patient Referral Form
This form is secure and completed with the patient’s consent. Please ensure the patient has agreed before submitting.
*
I confirm the patient has provided contsent for this referral.
1. Patient Details
Title
*
Please Select
Miss
Mr
Mrs
Ms
Dr
Mdm
First Name
*
Middle Name
Last Name
*
Preferred Name
Date of Birth
/
Day
/
Month
Year
Date
Gender
Please Select
Male
Female
Other
Email
Address
Street Address
Street Address Line 2
City
State
Postcode
Mobile Number
Home Number
Does your patient have a Medicare Card?
Yes
No
Medicare Number
IRN
Expiry Month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Expiry year
Does your patient have health insurance?
Yes
No
Private Health Provider
Membership Number
Does your patient have a DVA card?
Yes
No
DVA Card Type
Please Select
White card
Orange card
Gold card
DVA Number
Month
Please Select
January
February
March
April
May
June
July
August
September
October
November
December
Year
Condition/Disability
Does your patient have a Pension Reference Number?
Yes
No
Pension Reference Number
Has the patient received an Aged Care referral code from My Aged Care?
Please Select
Yes
No
Referral pending
Not applicable
Patient's My Aged Care Referral Code
Next of Kin
Relationship to Patient
Next of Kin - Contact number
2. Patient Medical Background
Past Medical History
What relevant past medical history does the patient have (e.g. chronic illnesses, surgeries, significant conditions)?
Specialist Involvement
Is the patient currently under the care of any specialists? Please list names, specialties, and reason for involvement.
Recent Pathology
Browse Files
Drag and drop files here
Choose a file
Has the patient had any recent pathology or investigations? Please provide details below or attach reports if available.
Cancel
of
Recent Pathology Details (if applicable)
Allied Health Services
Is the patient receiving support from allied health services (e.g. physiotherapy, occupational therapy, psychology)? Please provide details.
3. Referring Doctor Details
Referring Doctor’s Full Name
*
Practice Name
*
Practice Address
Street Address
Street Address Line 2
City
State
Postcode
Phone Number
*
Fax Number
Email
*
Provider Number
Reason for Referral
Comments
For security, please verify your submission below.
*
Submit →
Should be Empty: