Referral To	
(URGENT/IMMEDIATE REFERRALS ARE NOT SENT TO CRS, SEND DIRECTLY TO HOSPITAL)
Speciality:	     
Name of Specialist (if required):	     
Site:	     
Referral From	
Name:	«docname»
Provider Number:	«docprov»
Phone:	«sitephone»	Fax: «sitefax»
Address:	«sitename»
	«siteaddr1»
		«siteaddr2»«siteaddr3»
Once completed, please send referral to the Central Referral Service by one of the following methods.  Please note that for efficiency of process our preferred method is Secure Messaging.
Secure Messaging	See the CRS website for more information on available vendors.
http://www.gp.health.wa.gov.au/crs/about/refferal-forms.cfm	
Fax	1300 365 056	
Post	Central Referral Service
PO Box 3462
Midland WA 6056	
Patient Details	
	URMN Hospital No: (if known)      
First Name(s):	«givennames»	Family Name:	«surname»
Preferred Name:	«prefname»	Previous Name (e.g. Maiden):	     
Title:	«salutation»	Marital Status:	     
Country of Birth:	     	Birth Date:	«dob»
If born in WA, name of Hospital:	     	Gender:	«sex»
ATSI Status:	«ethnicity»
Address:
«address1»«address2»«address3»
Post code:	«postcode»	Mailing Address (if different): 
«address1_mail»«address2_mail»«address3_mail»
Email: «email»	
Telephone No:
Home:	«phoneh»
Mobile:	«phonem»	
Work:	«phonew»
Fax:	«phonef»	
Special Needs: 
Is an interpreter required?		If Yes, language/Dialect:      
Other Special needs: 	     
Medicare Eligible:		Medicare No:	«medicareno»	Ref: «subnumerate»	Expiry: «medicareexp»
DVA Card Number:	«dvano»	DVA Card Type:	«dvaexp»
MVIT 	Workers Compensation 
Next of Kin/Guardian 
Full Name:	«nextofkin»
Relationship:	     	Phone: 	«nextofkinphone»
Mother’s name at time of Birth:	     
Referral Details	
Fill this box for Immediate Referrals only (if the Patient must be seen by specialist within 7 days)
Has the referral been discussed with Registrar or Consultant?		(essential for Urgent Cases)
If yes, the clinician name:	     
Site:	     	Contact Number:	     
Referral advice given:       	
Is the referrer the usual GP for the patient?	     
If No, name of usual GP:	     
Contact number:	     
If the patient has been referred to this speciality for the same condition before, do they need to be referred to the same place again?	
Is the patient suitable for a Telehealth consult?	
Length of Referral:	
Is this a renewed referral?	
Reason for referring:
     
Clinical Information	
Observations	Percentile:      	Height: «heightweight_height»	Weight: «heightweight_weight»	
Current Problem:	«printcurrentconditions»	
Past History:	«printclinicalhistory»	
Current Medications:	«printcurrentmedication»	
Allergies:	«printallergies»	
Other:	     	
Family:	     	
Social History:	     	

Relevant Investigations and Tests (Please attach)

Pathology Provider:	     	Radiology Provider:	     

Other:      

Doctor Name:	«docname»	Provider Number:	«docprov»
Designation:	     	Date:	8/04/2016
Hospital Use Triage Only:
Urgent:	Semi Urgent:	Routine:
Comments:
Name:	Signature:	Date: