Date of referral

Robina Private Hospital Mental Health Web 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

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

Practice Address *

Street address *

City *

State *

Postcode *

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

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

Consultant / Specialist given name

Consultant / Specialist family name

Consultant / Specialist Provider Number

Patient Information

Given name *

Family name *

Date of Birth *

Medicare Number

Medicare Reference Number

Patient phone number *

Email

Patient address

City

State

Postcode

Funding source

Private Health Fund

Health fund policy number

DVA number

Please select card

White CardGold Card

Workers compensation claim number

Insurer

Case Manager

TAC claim number

DAN number

If other, please specify

Referral Information

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

Reason for referral *

Health HistoryPlease add relevant health / mental health history of patient including diagnosis if applicable.

Medications

Allergies

Do you have a preferred specialist for the private appointment?

Do you have a preferred specialist for the ADHD assessment?

Do you have a preferred specialist for the 291 assessment?

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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