Werribee Mercy Hospital 
Health Independence Program	

Referral Date: <<Miscellaneous:Date (short)>>
Phone: 8754 3800
Fax: 8754 3281	
Referral to
o Community Based Rehab
o Pulmonary Rehab	o Continence Clinic 
o Falls and Balance Clinic	o Complex Care
	
Patient Details	
Last/Family name:	<<Patient Demographics:Surname>>	First name:	<<Patient Demographics:First Name>>	
Previous last name:	<<Previous last name>>	Sex: 	<<Patient Demographics:Gender>>	
Date of birth:	<<Patient Demographics:DOB>>	ATSI status:	<<ATSI Status>>	
Address:	<<Patient Demographics:Address>>	Home telephone No.:  <<Patient Demographics:Phone (Home)>>	
Suburb:	<<Patient Demographics:City>>	Mobile number:	<<Patient Demographics:Phone (Mobile)>>	
Postcode:	<<Patient Demographics:Postcode>>	Email:	<<Patient Demographics:E-mail>>	
NOK/Carer:	<<NOK/Carer>>	Preferred contact method: << Preferred contact method>>	
NOK relationship: 	<<NOK relationship>>	Medicare no.:	<<Patient Demographics:Medicare Number>>	
NOK contact no.: 	<<NOK contact no.>>	Pensioner/Concession/Health/DVA No.: <<Pensioner/Concession/Health/DVA No.>>	
Alternative contact address*if applicable 	
Interpreter required:	o Yes   o No       Specify language: <<Interpreter language>>	
Previous Mercy patient:  o Yes   o No 	Mercy UR Number (if known): 	
The patient has agreed to the referral and the sharing of their personal and health information with the health service o Yes   o No	
Recent hospital admission *if applicable  	N/A  o   	Admission date:                               Discharge date:	
o Include the latest discharge summary including any handover from other professions	
Accommodation: <<Accommodation>>
______________________________	Ownership: <<Ownership>>
______________________________	Living arrangements: <<Living arrangements>>
______________________________	
Funding & Pension status
o Pension  Type: 
o DVA - <<DVA>>
o NDIS	Workcover: Pending o Approved o
Claim #:
TAC: Pending o Approved o
Claim #:	Substitute Decision Maker: o Yes o No 
Name:
EPOA: o Yes o No Name:
EPOA Medical: o Yes o No Name:
	
Referrer Details	
Referrer:	<<Doctor:Name>>	Provider number:	<<Doctor:Provider Number>>	
Referring Practice:	<<Practice:Name>>	Ward/Unit:		
Practice Address:	<<Patient Demographics:Address>>	
Suburb:	<<Doctor:City>>	
Postcode:	<<Doctor:Postcode>>	Phone No:	<<Doctor:Phone>>	
Email:	<<Doctor:E-mail>>	Fax:	<<Doctor:Fax>>	
Preferred method of communication:	<<Referrer, Preferred method of communication>>	

Patient’s usual GP (if not the same as referring doctor)	
Name:	<<Patient's usual GP Name>>	Clinic:	<<Patient’s usual GP Clinic>>	
Case Management
Case Manager *if relevant:		Phone:  	
Agency: 		Mobile:  	

Reason for referral / Care Coordination or treatment goals
<<Referral  Reason / Care Coordi'n / treatment goals>>	
Past medical
<<Clinical Details:History List>>	
Social history
<<Clinical Details:Social History>>
	
Current medication
<<Clinical Details:Medication List>>	
Clinical information
Allergies: 
<<Clinical Details:Allergies/Adverse Reactions>>	
Height (cm):  <<Height (cm)>>	Weight (kg):  <<Weight (kg)>>	BMI:  <<BMI>>	
Relevant investigation / test results
Please attach results as per the Statewide Referral Criteria for Specialist Clinics https://src.health.vic.gov.au
If the required investigation/test results are not attached the referral will not be accepted by Mercy Health
<<Summary:Investigation Results (Selected)>>
	
Additional medical history				Additional social history
Home oxygen: o Yes o No  	Does the client provide care for others?	
Continence:   Bladder - o Yes o No    Bowel - o Yes o No
Frequency/duration of problem:
Previous continence assessment o Yes o No  
Assessed by: 	 Approx. date: 	
Requires:  o General continence assessment 
o Pelvic Floor Physiotherapy 
o ISC Instruction 	ACAS Assessment:  o Yes  o No  o Required 
Assessment outcomes 
o HLC/LLC o Respite/Permanent 
o Level 1 / 2 package o Level 3 / 4 package 

My Aged Care referral o Yes o No o Required	
Other notes/services (in place or arranged on discharge e.g. management to date, impact of the problem on the patient)

Doctor’s signature:		Date:	<<Miscellaneous:Date (short)>>	
Appointment details will be sent to referrer 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.                This form constitutes a valid referral to Werribee Mercy Hospital provided all requested details are complete.