Living Well with Persistent Pain in the North

Please fax to: 08 8252 9433
Attention: Pain Clinic Coordinator

Living Well with Persistent Pain Program
Referral form
 PATIENT DETAILS 
Date of Referral: <<Date of referral>>	Date of Birth:  <<Patient Demographics:DOB>>	Gender:    <<Patient Demographics:Gender>>	
Title: <<Patient Demographics:Title>>	Surname: <<Patient Demographics:Surname>>	First Name: <<Patient Demographics:First Name>>	Middle Name: <<Patient Demographics:Middle Name>>	
Address: 
 <<Patient Demographics:Full Address>>	
Daytime contact number:              
Home:  <<Patient Demographics:Phone (Home)>>	Work: <<Patient Demographics:Phone (Work)>>	Mobile: <<Patient Demographics:Phone (Mobile)>>	

PATIENT PRESENTATION
Clinical History:<<Clinical Details:History List>>

Current Medication List: <<Clinical Details:Medication List>>	

PAIN MEDICATION HISTORY
Medication previously tried:<<Medication previously tried:>>

	

PAIN MANAGEMENT HISTORY
Has the patient previously visited a pain clinic or participated in a pain management program?     <<Previous visit to pain clinic or pain mng program?>>

If yes, where and when:<<If Yes, where and when:>>

What other pain management strategies have been tried?<<Other pain management strategies tried?>>

I request for my patient to participate in the Living Well with Persistent Pain program which includes: 

<<I request for my patient to receive>>

As part of this, I would like for my patient (please indicate):

<<As part of this, I would like for my patient:>>

As the referring GP, I agree to:

<<As the referring GP, I agree to:>>

The patient meets all of the following eligibility criteria:

<<The patient meets all the following eligibility criteria>>

REFERRING DOCTOR/ORGANISATION DETAILS
**A GP Sign off is mandatory for this referral to be accepted** 
Please stamp/insert details:

Doctor’s Signature:__________________       

Date: <<Miscellaneous:Date>>

This referral is valid for 12 months. 

On the receipt of this referral, the patient will be placed on the waiting list and contacted with details of the Living Well with Persistent Pain Program. 

Referrals are addressed upon receipt with all considered equally.

PATIENT CONSENT:
I understand that this referral is for the provision of pain management services, which include an assessment, the development of a plan for treatment, and education sessions. I agree to be a part of this process with the knowledge that:
Please circle yes or no to the following questions

My medical history will be shared with the necessary health serive providers where relevant: Yes / No 

The information collected is private and will be kept confidential unless agreed upon: Yes / No

My GP has explained to me the reason for participating in this program: Yes / No 

I understand that my treatment will be monitored and communicated between my treatment team including my GP: 
Yes / No

All personal information gathered will remain confidential and secure with my treating team: Yes / No 

Name: ___________________________

Signature:_______________________   

Date: <<Miscellaneous:Date>>