ࡱ> BDA7 ebjbjUU 067|7| Rlv v v 8 D $"  (  $ hN NN KN"  Nn``  hv p``,a0`))`______________________________________________ eMedisafe An Electronic Referral Process ________________________________________________ To:  FORMTEXT       From: Regarding  FORMTEXT       (Our Client ID:  FORMTEXT      ) Date:  DATE \@ "MMMM d, yyyy" August 4, 2000 ________________________________________________ SOURCE OF REFERRAL Contact Person:  FORMTEXT       Address: Phone: Email address: ________________________________________________ REASON FOR REFERRAL Reason for referral and/or type(s) of assistance being sought:  FORMTEXT        ASK \* MERGEFORMAT If the Need is Urgent, describe the situation:  FORMTEXT       Has the client agreed to this referral?:  FORMDROPDOWN  _________________________________________________ CLIENT INFORMATION Name:  FORMTEXT       Address:  FORMTEXT       Home Phone  FORMTEXT       Other Phone  FORMTEXT       Prefers to be Called:  FORMTEXT       Municipality:  FORMTEXT       Gender:  FORMDROPDOWN  Age/ Date of Birth?  FORMTEXT       Country of Birth?  FORMTEXT       Preferred Language?  FORMTEXT       English Proficiency?  FORMTEXT       Is an Interpreter Required?  FORMDROPDOWN  Does the client identify themselves as an aboriginal or Torres Strait Islander person?:  FORMDROPDOWN  Household Type?  FORMDROPDOWN  Income Source?  FORMTEXT       Pension Type?  FORMTEXT       Medicare Number:  FORMTEXT       Health Fund and Number:  FORMTEXT       _________________________________________________ CLIENT CONTACTS Client's lives with?  FORMDROPDOWN  Does the client have informal assistance is available on a regular basis (e.g. carer, friend, social club or church group)?  FORMTEXT       ASK \* MERGEFORMAT  Is the client living at their normal address? If not please provide details:  FORMTEXT       Please provide contact details for a carer or other alternative contact person:  FORMTEXT       Relationship of this person to the client?  FORMTEXT       _________________________________________________ SUPPLEMENTARY DATA Social Situation:  FORMTEXT       Major Diagnosis and Past History:  FORMTEXT       Recent Investigations/Results:  FORMTEXT       _________________________________________________ MEDICATIONS Any relevant medications issues? If yes please provide details:  FORMTEXT       _________________________________________________ OTHER INFORMATION Additional Information in support of this referral:  FORMTEXT       _________________________________________________ I would appreciate notification on the progress of this referral within SEVEN days. Thank you for receiving this referral. 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