Victorian Statewide Referral Form	General Practice version Jul 2019

REQUEST FOR BARWON HEALTH CANCER SERVICES 		FAX 03 4215 2743 (Public)
									FAX 03 4215 2836 (Private)		
GP Referral | | Referral Date: <<Miscellaneous:Date (long)>> Feedback Requested:  Yes

Referral to:
Andrew Love Cancer Centre
Telephone: 03 4215 2700
Fax: Public 03 4215 2743
Private 03 4215 2836
<<Pts have a choice of public or private clinics >>
<<No Out of Pocket expenses for cancer services >>
Public or Private referral: <<Are you referring this patient as public or private?>>

Public service requested: <<If public oncology select service required>>

Private service requested:
<<If Private Medical Oncology - requested consultant>>

<<If Private Radiation Oncology -requested consultant>> 

<<If Private Haematology - requested consultant>>

Urgency: <<Urgency>>
Referral Length: <<How long is this referral for:>>

Referring General Practitioner:
<<Doctor:Name>> 
<<Practice:Name>>
<<Practice:Address>>
HPI-O: 
Phone: <<Practice:Phone>>   Fax: <<Practice:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>
HIPI-I:  <<Doctor:HPI-I>>

Consumer details:
Name:	<<Patient Demographics:First Name>> <<Patient Demographics:Surname>>
Date of Birth:	<<Patient Demographics:DOB>>
Age:                        <<Patient Demographics:Age>>
Preferred Name/s:	<<Patient Demographics:Greeting>>
Sex:	<<Patient Demographics:Sex>>
Title:	<<Patient Demographics:Title>>
IHI:    <<Patient Demographics:IHI>>

ATSI:  <<Patient Demographics:ATSI>>

Contact Address:	<<Patient Demographics:Full Name>>
	<<Patient Demographics:Address>>
	<<Patient Demographics:City>>  <<Patient Demographics:State>>    <<Patient Demographics:Postcode>>
Phone:	<<Patient Demographics:Phone (Home)>>
Work:	<<Patient Demographics:Phone (Work)>>
Mobile:	<<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>

Alternative Contact:

 
Interpreter required: <<Does the patient require an interpreter?>> | | DVA Number: <<Patient Demographics:DVA Number>>
Preferred language is: <<If interpreter needed, which language>> | | Insurance: <<Patient Demographics:Health Insurance>>
Pension Card Number: <<Patient Demographics:Pension Number>> | | Medicare Number: <<Patient Demographics:Medicare Number>>

Date patient consented to referral: <<Miscellaneous:Date (short)>>
Consent to share information: <<Consent to share information>>
Patient consents to MBS bulk billing clinic: <<Consent to MBS Bulk Billing Clinic>>

WestVic HealthPathways provide guidance in patient assessment, management and referral. 	<<HealthPathways provide guidance in AxMx Referral>>

Reason for patient referral: 

Please consider telehealth for the this patient:  <<Consider Telehealth for this patient>>

<<Reason for Referral (incl.Dx or prov Dx if known)>>

Is tissue Dx known?:  <<Is tissue Dx known?>>
<<If No, please organise tissue Dx if feasible>>
What has the patient been told?:  <<What has the patient been told?>>
Recent PHx Medication list review undertaken:  <<Pl ensure PHx Medication list review is undertaken>>

Specialists involved? <<Specialists involved in management>>
Other Relevant Information:  <<Other relevant information>>

Current Medication:
<<Clinical Details:Medication List>>

GP management plan: <<GP Management plan?>>
Team Care Arrangement:  <<Team Care Arrangement?>>

Family History: <<Is there a FHx of cancer?>>

Past Medical History: 
<<Clinical Details:History List>>

Progress Notes:
 <<Summary:Progress Notes (Selected)>>

Investigation Results:
<<Summary:Investigation Results (Selected)>>

Social History: <<Clinical Details:Social History>> 
Smoking HX:  <<Clinical Details:Smoking>>,  
If smoker, has cessation program been discussed?: <<If smoker, has cessation program been discussed?>>

Warnings: <<Clinical Details:Warnings>>

Allergies: <<Clinical Details:Allergies>>

Patient Name: <<Patient Demographics:Surname>>, <<Patient Demographics:First Name>>  DOB:  <<Patient Demographics:DOB>>

GP Referral:  <<Doctor:Name>>,  Patient: <<Patient Demographics:Full Name>>,  <<Miscellaneous:Date>> 	Page