UR No.: 	<<UR No.>>
Surname: 	<<Patient Demographics:Surname>>
First Name: 	<<Patient Demographics:First Name>>	
WMH MEDICAL DAY STAY
WAITLIST FORM	DOB: 	<<Patient Demographics:DOB>>	Sex:  	<<Patient Demographics:Gender>>
Address: :	<<Patient Demographics:Address>>
Suburb: 	<<Patient Demographics:City>>	Postcode: 	<<Patient Demographics:Postcode>>	
Interpreter Required: 	<<Interpreter Required>>
Language spoken: 	<<Language spoken>>	Primary Carer: 	<<Primary Carer>>
Contact No.: 	<<Primary Carer Contact No>>	
Medicare No: <<Patient Demographics:Medicare Number>>	Contact Number: 	(H): 	<<Patient Demographics:Phone (Home)>>		M): <<Patient Demographics:Phone (Mobile)>>	
Referring Dr: <<Doctor:Name>>	Provider No: <<Doctor:Provider Number>>	
GP Name: <<Usual GP Name (if different from referring Dr)>>	Clinic: <<Clinic Name (usual GP)>>	Contact No: <<Contact No (usual GP)>>	
Has the patient previously attended WMH?  <<Has the patient previously attended WMH>>	If Yes – Was patient registered under the same name?  <<Was patient registered under the same name>> 
Previous name:  <<Previous name (if previous attended WMH)>>	
o Category 1 (Urgent)
Admission desirable for a condition that has the potential to become life threatening or an emergency.	o Category 2 (Semi-Urgent)
Admission desirable for a condition causing some pain, dysfunction or disability but which is not likely to deteriorate quickly or become an emergency.	o Category 3 (Non Urgent)
Admission at some time in the future for a condition causing minimal or no pain, dysfunction or disability, which is unlikely to deteriorate quickly and which does not have the potential to become an emergency.	
Referrals for Iron infusions require recent (<3 months) pathology results (FBE and Fe studies).
Incomplete referrals will be returned.	
Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>	
Principal Diagnosis: <<Principal Diagnosis>>	
Ambulation Status:  <<Ambulation Status>>	
Relevant Past History: 
<<Clinical Details:History List>>	
Proposed procedure or treatment required: <<Proposed procedure or treatment required>>	
Blood product: 
Specify......................................	IVIg:
Specify ........................................	Portacath flush	o
PICC line dressing	o	
Iron infusion	o	Infliximab	o	Trial of Void	o	
Venesection and hydration	o	Tysabri	o	CGMS	o	
Chemotherapy	o	Other: (specify) 	
Vedolizumab	o	Dose: 	Frequency: 	
Signed: 	Date:  <<Miscellaneous:Date (short)>>	
Admission Type:  Public  o       Private  o         DVA   o       Overseas visitor  o    Defence  o	
For long term/ ongoing referrals, please ensure a new referral is sent every 12 months with any changes or updates to medical history.	
Please send completed referral with required pathology results and health summary to:
Medical Day Stay
Werribee Mercy Hospital
300 Princes Hwy Werribee, 3030
Fax: 8754 3535	
Hospital Use only: 	
Date placed on Waiting List::	 				Date referral received:	
Scheduled admission date: