Refomatted HC Referral Form Aug2018 doc 2026

1. Click ‘Get Form’ to open the Refomatted HC Referral Form Aug2018 in our platform.
2. Begin by entering the referral date at the top of the form. Next, fill in the patient details including their Alfred UR Number (if known), date of birth, first name, surname, and gender.
3. Provide the patient's address and contact phone numbers for home, work, and mobile. If an interpreter is required, specify the language needed.
4. In the referring doctor section, input their provider number, name, signature, mailing address, contact phone number, and fax number.
5. Select the referral duration by checking one of the options: Opinion Only, 3 Months, 12 Months, or Indefinite.
6. Detail the reason for referral and any relevant clinical details in the provided space. Include background medical history and medications as necessary.
7. Indicate any recent investigations attached by checking appropriate boxes for echocardiogram or blood tests.
8. Assess priority by selecting from Urgent (1 week), Semi Urgent (1 month), or Next Available options.
9. Specify requested investigations such as Exercise Stress Test or Echocardiography by checking relevant boxes.
10. Finally, indicate which clinic to refer to and provide any additional notes before saving your completed form.

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