ࡱ> 9;87 =bjbjUU %47|7|= l L D z $* Jz3 3  H        %q  `% F=q^0E, .q ________________________________________________ eMedisafe: A Secure Electronic Referral Process ________________________________________________ To:  MERGEFIELD RefTitle RefTitle  MERGEFIELD RefFirstName RefFirstName  MERGEFIELD RefLastName RefLastName Address:  MERGEFIELD RefAddress RefAddress  MERGEFIELD RefAddress1 RefAddress1  MERGEFIELD RefCity RefCity  MERGEFIELD RefPostCode RefPostCode Phone:  MERGEFIELD RefWPhone RefWPhone Fax:  MERGEFIELD RefFax RefFax Date:  TIME \@ "dddd, d MMMM yyyy" Friday, 4 August 2000 ________________________________________________ SOURCE OF REFERRAL  MERGEFIELD DrName DrName  MERGEFIELD PracticeName PracticeName  MERGEFIELD PracticeAddress PracticeAddress  MERGEFIELD PracticeCity PracticeCity  MERGEFIELD PracticePcode PracticePcode Phone:  MERGEFIELD PracticePhone PracticePhone Fax:  MERGEFIELD PracticeFax PracticeFax _________________________________________________ CLIENT INFORMATION  MERGEFIELD PatTitle PatTitle  MERGEFIELD PatFirstName PatFirstName  MERGEFIELD PatSurname PatSurname  MERGEFIELD PatAddress PatAddress  MERGEFIELD PatAddress PatAddress  MERGEFIELD PatCity PatCity  MERGEFIELD PatPCode PatPCode Home Phone  MERGEFIELD PatHPhone PatHPhone Medicare Number  MERGEFIELD PatMediNum PatMediNum Prefers to be Called:  MERGEFIELD PatPreferredName PatPreferredName Date of Birth  MERGEFIELD PatDOB PatDOB (Age  MERGEFIELD PatAge PatAge) Gender:  MERGEFIELD PatSex PatSex Our ID Number for the Patient:  MERGEFIELD PatUR PatUR SUPPLEMENTARY DATA Please review the data and answer the following questions where they are relevant to this referral  MERGEFIELD StopandEditHere StopandEditHereActive Problems:  MERGEFIELD ActiveProblems ActiveProblemsFamily History:  MERGEFIELD FamilyHistory FamilyHistoryWhat medications is the client taking?  MERGEFIELD MedicationList MedicationListAny recent investigations /results relevant to the referral? REASON FOR REFERRAL What is the reason for the referral and/or type(s) of assistance being sought? If the need is urgent, please describe the situation: Has the client agreed to this referral?: OTHER ITEMSIs the client living at their normal address? If not please provide details: Any language/communication assistance required? If yes, what language?: Does the client identify themselves as an aboriginal or Torres Strait Islander person?: Any Relevant Contact or Carer Details? OTHER INFORMATION Please add any additional information in support of this referral?  I would appreciate advise on the progress of this referral within seven days. 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