SMART Clinic
Supplementary Information		Referral Date: <<Miscellaneous:Date (short)>>
General enquiries:
Ph 1300 369 019 (24 hours)	

Referral to
o SMART (Symptom Management and Referral Team) clinic	Phone: 8754 6700
Fax: 8754 6710	Outpatient Clinics, Werribee Mercy Hospital	
This document must be attached to the 2 page Werribee Mercy Hospital Outpatient Clinic Referral form when referring to the SMART clinic. This document in isolation does not constitute a valid referral.
(https://health-services.mercyhealth.com.au/health-professionals/refer-a-patient/referral-instructions-and-templates/#content-referral-forms--templates)	

Patient details
Last/Family name::	<<Patient Demographics:Surname>>	Given Name:	<<Patient Demographics:First Name>>	
Date of birth:	<<Patient Demographics:First Name>>	Sex:	<<Mercy Health UR No>>	
Address:	<<Patient Demographics:Address>>			
Suburb:	<<Patient Demographics:City>>	Mobile number:	<<Patient Demographics:Phone (Mobile)>>	
Postcode:	<<Patient Demographics:Postcode>>			

Referring Doctor Details
Referring Doctor:	<<Doctor:Name>>	
Practice Name:	<<Practice:Name>>	

Additional medical history/treatment
Primary diagnosis (include histology if applicable):	Secondary diagnosis:	
<<Primary diagnosis (include histology if applicable)>>	<<Secondary diagnosis>>	
Date of primary diagnosis: <<Date of primary diagnosis>>	Date of secondary diagnosis: <<Date of secondary diagnosis>>	
Additional medical history (attach relevant imaging, blood test results, medication list etc)	

Key Symptom issues:	
o Pain	o Tiredness	o Nausea	o Depression	o Anxiety	o Shortness of breath	
o Drowsiness	o Appetite	o Wellbeing	o Constipation	o Diarrhoea	o Other:	

Advance Care Planning
Does the consumer have an Advance Care Plan?	o Yes  o No  o Not stated/unknown	If yes, where is it kept?	
Does this include a Refusal of Treatment Certificate or other documentation limiting treatment?	o Yes  o No  o Not stated/unknown		
Does the consumer have a nominated substitute decision maker (enduring power of attorney medical treatment) in relation to medical decisions?	o Yes  o No  o Not stated/unknown	If yes, name of substitute decision maker?	

Is the client aware of the diagnosis and prognosis?	o Yes  o No	If not, why? 	
Is the family aware of the diagnosis and prognosis?	o Yes  o No	If not, why? 	

Doctor’s signature:		Date:		
Appointment details will be sent to referring GP and the patient.

IMPORTANT NOTICE – PRIVILEGED AND CONFIDENTIAL MESSAGE
This facsimile transmission is intended for the exclusive use of the person or hospital to which it is addressed and may contain information that by law is privileged or confidential. If the reader of the facsimile transmission is not the intended recipient, you are hereby notified that any disclosure, distribution of copying of this transmission is prohibited by law, and the contents must be kept strictly confidential. If you have received this transmission in error, kindly notify us immediately and return the original to us at the above address.