Date of referral

Toronto Private Hospital Mental Health Online Referral

Referrer Information

Title

DrA/ProfProf

Given name *

Family name *

Provider Number *

Provider Qualification

Specify other qualification *

I would like to be kept informed by: *

EmailTelephoneFaxLetter

Practice phone number *

Practice fax number

Practice Name

Would you like to be contacted about CPD education events and the hospital’s services?

Please provide your email if you wish to receive a copy of this referral submission

If this referral is being completed by a registrar or intern, details of the referring consultant must be provided below

Consultant given name

Consultant family name

Consultant Provider Number

Patient Information

Given name *

Family name *

Date of Birth *

Medicare Number

Medicare Reference Number

Medicare Expiry Date

Patient phone number *

Email

Patient address

City

State

Postcode

Funding source

Private Health Fund

Health fund policy number

DVA number

Workers compensation claim number

Insurer

Case Manager

TAC claim number

If other, please specify

Referral Information

The patient is aware of the referral and agrees to be contacted by Toronto Private Hospital
*

Reason for referral *

The patient is being referred for *

Hospital AdmissionDay Patient Program/sPrivate AppointmentOther

Do you have a preferred specialist for the private appointment?

If other support required, please provide details *

rTMS information

Is the patient claiming medicare? *

YesNo

Patients must be eigible to claim medicare for referral to be accepted

If patient is claiming the medicare rebate, please confirm the following

First time recipient of TMS therapyAged 18 years and olderDiagnosis of a major depressive disorderPatient has trialled two different classes of anti-depressant medicationsPatient has engaged in psychological therapy

Details of medication trials conducted in the past year

Medication name

Dose range

Duration (weeks)

Date commenced

Please specify other conditions which may affect treatment

Additional considerationsInclude food, drug and special needs including mobility or access issues

Upload referral letter, if needed

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If your patient is in acute crisis which presents a risk to the patient (i.e. is actively suicidal) or others, please contact your local Emergency Department. Submission of an online referral does not does not automatically constitute acceptance of the referral. We will contact your patient, and you will be advised of the outcome.

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