NBMLHD Community Health Services
Client Registration & Request for Service GP Fax Form
Phone 1800 222 608 (Between 0900 - 1600 Monday to Friday)
Fax  4732 9485 (24 hours)
__________________________________________________________________________________
Please indicate area of service required:
<Indicate area of service required:>
__________________________________________________________________________________

Patient Details:

Title : <PtTitle> 			Last Name:  <PtSurname>	 		First Name:     <PtFirstName>
Sex: <PtSex>			Date of Birth:  <PtDoB>
Country of birth: <Country of Birth>	Indigenous status (Mandatory):  <Indigenous Status>        
Patient Address: 
<PtAddress>
Telephone (Home):  <PtPhoneH>
	    (mobile): <PtPhoneMob>
	    (work):    <PtPhoneWk>
Preferred Language: <Preferred Language>		Needs Interpreter:  <Needs Interpreter>
Medicare Card:  <PtMCNo>
DVA Number: <PtDVANo>	DVA Card:   Colour <DVA Colour>   
DVA Card Expiry Date:  <DVA Expiry Date>
__________________________________________________________________________________
Current GP/LMO details:                                
<DrName>
<DrAddress>        
Telephone:  <DrPhone>
Facsimile No: <DrFax>

Date of Referral: <TodaysDate>
Is the referrer a GP?: <Is the Referrer a GP?> 
Other referrer's details: 
<If not, Other referrer's name, position and phone number>
_______________________________________________________________________________

Person for Contact: <Full Name Person for Contact> 	Relationship: <Relationship to person for contact>
Contact details: 
Phone (Home): <Person for contact ph home> 	(Work): <Person for contact ph work> 	  Mobile: <Person for contact ph mobile>

Parent/Guardian Full Name (for children 0-18yrs)
<Parent/Guardian Full Name>
Phone: <Parent/guardian phone number>
__________________________________________________________________________________

Description of Presenting Issue / Problem:
<Presenting issue/problem>
            
Service Requested:
NOTE: Request for medication administration requires GP/Medical authority
<Service requested>

Relevant Medical history / investigations:
<SelectedPMH>

Allergies:
<Reactions>

Current Medications:
<SelectedRx>

Details of past history: 
<Details of past history>

Additional information to assist referrer to prioritise:
<Additional information to assist referrer to prioritise>

(CACC only) Falls Screen:  (Note in each question below: Yes, No or Unknown)
1.	Has the client had a fall in last six months? <Has client had a fall in last 12 months?>
2.	Does the client take 4 or more medications? <Do they take 4 or more medications?>
3.	Has the client ever had a stroke or do they have Parkinson's disease? <Has client had a stroke?>/<Does the client have Parkinsons' Diseases?>
4.	Does the client have any problems with their balance? <Does client have balance problems?>
5.	Does the client need to use their arms to get up from a chair? <Do they use their arms to get up from a chair?>

Mobility aid (if any): <Mobility aid (if any)>

Safety Issues:
Domestic Violence:<Domestic Violence>
Aggressive Behaviour: <Aggressive Behaviour>
Community Services reports/Known to Community Services: <Known to Community Services?>

Other alerts:
<List other alerts>