PATIENT INFO		REFERRAL DETAILS	
Sticker /UR No:			Referrer Name:	Treating Doctor.Name	
Family Name:	Patient Demographics.Surname		Role:	Treating Doctor.Qualifications	
Given Name:	Patient Demographics.First Name		Email:	Treating Doctor.E-mail	
Sex:	Patient Demographics.Gender		Phone (Mobile preferred):	Treating Doctor.Phone	
Address:	Patient Demographics.Address		Preferred method of contact:		
Suburb:	Patient Demographics.Mailing Suburb		P/Code:	Patient Demographics.Mailing Postcode		DOB:	Patient Demographics.DOB		Patient is 13 years or older:	Patient Demographics.Age			If My Home Hospital was not available it is expected this patient would require admission to a public hospital:		
Telephone:	Patient Demographics.Phone (Home)		Date of referral: Miscellaneous.Date Time: Miscellaneous.Time	
Mobile:	Patient Demographics.Phone (Mobile)		Requested service commencement	
Is the patient of Aboriginal or Torres Strait Islander origin?:	Patient Demographics.ATSI Status		Date: 
Time:	
Address where care to be provided – if not usual address. Please note eligibility is based on location of service delivery				Address:				Reason for Admission:		USUAL GP DETAILS 
(If available and if not referred by GP)		
Suburb:			Name:		
P/Code:			Practice name:		
Please indicate if the patient has a third-party decision maker (should this be required)		Phone:		PATIENT DETAILS		
Parent or Guardian (for patient under 16 years of age):		Does the patient require an interpreter		
Substitute Decision-Maker appointed under an advance care directive:		(if yes specify language)			Patient holds a Medicare card			
Person Responsible:			Where possible provide card number	Patient Demographics.Medicare Number	
Name:			Relationship:			Phone:			Referral Source:	Practice.Name			If patient holds private health insurance or is a DVA card holder, please confirm that patient has elected not to use that funding and agrees to be admitted to MyHH as a public patient:		
			Confirm patient is not a compensable patient (ie. WorkCover, MVA insurance) Compensable patients cannot be accepted by MyHH:		

REFERRER SIGNATURE
I confirm I have discussed the My Home Hospital service with the patient or their Substitute Decision-Maker (as identified above) and they have consented to a referral to My Home Hospital.	
Signature:	Print name:
Treating Doctor.Name	Date:
Miscellaneous.Date	

CLINICAL INFORMATION (information can also be supplied through attaching information)	
Presenting history	
Dear Colleague,
...
	
Relevant past medical history	
Clinical Details.Selectable Encounter Notes	
Allergies / adverse reactions	
Clinical Details.Allergies	
Observations/vital signs – please provide baseline observations to enable assessment of clinical suitability	
Clinical Details.Selected Most Recent Measures	
Treatment already provided and/or commenced	

	
INFECTION CONTROL ALERTS: 	
Hep B or C	HIV	MRSA	VRE	Other MRO (specify)	
					
Respiratory precautions required?: 	
If your patient has recently been in hospital, are any of the existing hospital acquired complications present currently?	
Pressure Injury:	Falls resulting in fracture or intracranial injury:	Healthcare associated infection:	Renal failure:	
Venous thrombosis:	Medication complications:	Delirium:	Incontinence:	
PLEASE ATTACH WHERE AVAILABLE	
Health Summary	Mental Health Assessment	Discharge Summary	Medication Summary	
Wound Chart	PICC/Other Vascular line details	Advance Care Directive	IDC/SPC Management	
Investigations (pathology/imaging)	Other information attached (specify):