Victorian Statewide Referral Form	General Practice version  April 2024

REQUEST FOR SMOKING CESSATION SERVICES / BE SMOKEFREE CLINIC

Refer via Information & Access Service
ReferralNet: (BH CHRIAS)
Fax: 03 4215 7795		

GP Referral | | Referral Date: <<Miscellaneous:Date (short)>> Feedback Requested:  <<Feedback requested>>

Referral to:
Smoking Cessation
"Be Smokefree" Clinic

Ph: 
Information & Access: 03 4215 7700

Referral Urgency: <<Referral Urgency>>
Referral valid for: <<Referral valid for>>

Referring General Practitioner:
Name:<<Doctor:Name>>
Practice: <<Practice/Location:Name>>
Address:<<Practice/Location:Address>>
Phone: <<Practice/Location:Phone>>  
Fax:  <<Practice/Location:Fax>>
Email: <<Doctor:E-mail>>
Provider No.: <<Doctor:Provider Number>>

Patient/Client/Consumer details:
Title: <<Patient Demographics:Title>>
First name: <<Patient Demographics:First Name>>
Surname: <<Patient Demographics:Surname>>
Preferred Name: <<Patient Demographics:Known As>>
Date of Birth: <<Patient Demographics:DOB>>  Age: <<Patient Demographics:Age>>
Gender: <<Patient Demographics:Gender>>
ATSI: <<Patient Demographics:ATSI>>
Interpreter required: <<Patient Demographics:Requires Interpreter>>
Preferred language is: <<Patient Demographics:Language Spoken>>
Please consider Telehealth for this patient:<<Please consider Telehealth for this patient:>>
Cultural safety requirements: <<Cultural safety requirements?>>
Access/Support requirements: <<Access/support requirements?>>

Address: <<Patient Demographics:Address>>
Mobile: <<Patient Demographics:Phone (Mobile)>>
Email: <<Patient Demographics:E-mail>>
Home Phone:  <<Patient Demographics:Phone (Home)>>
Work Phone: <<Patient Demographics:Phone (Work)>>
Preferred method of communication: <<Patient preferred contact method>>

Medicare: <<Patient Demographics:Medicare Number>> Expiry: <<Patient Demographics:Medicare Expiry Date>>
Pension/HCC: <<Patient Demographics:Pension Number>>
DVA: <<Patient Demographics:DVA Number>>
Insurance: <<Patient Demographics:Health Insurance>>

NOK/Carer/Alternate contact:
Name: <<Patient Demographics:Next of Kin>> 
Phone: <<Patient Demographics:Next of Kin Phone>>
Relationship: <<Patient Demographics:Next of Kin Relationship>>

Consent to referral: <<Consent to referral?>> 
Consent to share information: <<Consent to share information?>>
Consent to contact from service: <<Consent to contact from service?>>
Is this a 2nd referral for the same problem: <<Is this a 2nd referral for the same problem?>>
Usual GP (if not referrer):  <<Usual GP (if different to referrer)- Name/Practice>>

WestVic HealthPathways provides guidance in patient assessment, management and referral. 
 			<<HealthPathways Barwon guidance in Ax Mx referral>>

Preferred Clinic: <<Preferred clinic>>

Smoking Status: <<Clinical Details:Smoking>>
Readiness to quit smoking: <<Readiness to quit smoking>>
Previous quit attempts:  <<Previous quit attempts- include number & method>>

Relevant Co-morbidities / issues: 
<<Please indicate relevant conditions / issues>>

Respiratory / Lung disease?  <<Respiratory / Lung disease?  >>

Diabetes? <<Diabetes? >>

Heart Disease? <<Heart Disease?>>

Pregnancy? <<Pregnancy? >>

Other substance abuse? <<Other substance abuse?>>

Planned surgery? <<Planned surgery?>>

Mental Illness?  <<Mental Illness- please specify>>

Concern about children's health?  <<Concern about children's health? >>

Other: <<Other- please specify>>

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

Social History:
<<Clinical Details:Social History>>

Family History:
<<Clinical Details:Family History>>

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

Alerts:
<<Clinical Details:Warnings>>

Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>

Alcohol History:
<<Clinical Details:Alcohol>>

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

Electronically signed: <<Doctor:Name>>

GP Referral:  <<Doctor:Name>>,  <<Miscellaneous:Date (short)>>Patient: <<Patient Demographics:Full Name>>, DOB:<<Patient Demographics:DOB>>  <<Miscellaneous:Date>> 	Page