Referral To	
o	Mercy Palliative Care Sunshine
Community Palliative Care 
3 Devonshire Road
Sunshine, VIC 3020
1300 369 019 (phone)
03 9364 9198 (fax BH)
03 8754 3741 (fax AH)	o	Werribee Mercy Hospital
Inpatient Gabrielle Jennings Centre
300 Princes Highway
Werribee, VIC 3030
03 8754 3731 (phone)
03 8754 3735 (fax)	o	
Non-malignant SMART Outpatients Clinic
Werribee Mercy Hospital
300 Princes Highway
Werribee, VIC 3030
03 8754 6710 (fax)	

Provider No:	
<DrProviderNo>	

Signature:	

	
Referrer Details	Patient Details	
Name:	<DrName>	Surname:	<PtSurname>	
Clinic:	<Practice>	Given Name(s):	<PtFirstName>	
Address:	<DrStreet>, <DrCity>  <DrPostcode>	Address:	<PtStreet>, <PtCity>  <PtPostcode>	
Phone:	<DrPhone>	Phone:	<PtPhoneH>	
Mobile:	<DrMobilePhone>	Mobile:	<PtPhoneMob>	
Email:	<DrEmail>	Email:	<PtEmail>	
Relationship:		Gender:	<PtSex>	
Primary Carer / NOK	Date of Birth:	<PtDoB>	
Surname:		Country of Birth:	<Country of Birth>	
First Name:		Indigenous:	o No o Aboriginal o TS Islander	
Address:		Preferred Language:	<Preferred Language>	
Phone:		Interpreter Needed:	o Yes o No	
Mobile:		Diagnosis: 	o Malignant o Non-Malignant	
Email:		General Practitioner	
Relationship:		Name:		
Secondary Carer / NOK	Clinic:		
Surname:		Address:	  	
First Name:		Phone:		
Address:		Fax:		
Phone:		Email:		
Mobile:		Medicare / Insurance	
Email:		Medicare No:	<PtMCNo>	
Relationship:		PH Insurance:	o Yes o No	
Other Carer / Case Manager	PHI Provider:	<PtHealthIns>	
Surname:		PHI Card Number:		
First Name:		DVA:	<PtDVANo>	
Address:		DVA Card Number:	o No o Gold o White	
Phone:		Other Information	
Mobile:			
Email:			
Relationship:			

Client Name:	<PtName>	DOB:	<PtDoB>	UR/MRN:		
Service requested:	o IPPC o IPPC Back Up Bed o Community Palliative Care o Outpatient Clinic 	
Reason for Referral:	o Symptom Management o EOLC ☐Other:	
Priority:	o Urgent (within 2 days) o Semi-urgent (can wait 1 week) o Non-urgent	
Diagnosis / Recent History / Planned Treatments	

	
Past Medical History	

	
Clinical Information Supporting Referral for Service	
Phase of Care:	o Stable o Unstable o Deteriorating o Terminal	
Physical Symptom	Additional Information	
o Pain		
o Dyspnoea		
o Nausea		
o Vomiting		
o Bowel		
o Tiredness		
o Appetite		
o Other		
Psychological Symptom Issues:	o Anxiety o Depression o Confusion o Restlessness o Existential Distress o Other	
Family / Caregiver Issues:	o Anxiety o Distress o Exhaustion o Unable to meet care needs o No carer o Complex Need	

o Lives alone o Lives with family/other 	

o Significant health issues:	

	
Current interventions:	o Oxygen o Syringe Driver o IDC o Ext. Drains o PPM/AICD o Wound	

o Other:	

	
TO ACTION THIS REFERRAL THE FOLLOWING IS MANDATORY	
o DISCHARGE SUMMARY
o PATHOLOGY & RADIOLOGY REPORTS
o EQUIPMENT PROVIDED	o OTHER RELEVANT CLINICAL INFORMATION
o ANTICIPATORY MEDICATION ORDERS
o SERVICES ARRANGED OR IN PLACE	ADDITIONAL INFORMATION CAN BE ATTACHED	
MERCY HEALTH USE ONLY Referral Accepted:	o YES o NO