Date of referral

Robina Private Hospital Rehabilitation and Medical Referral

Referring site information

Referring hospital

Bed / ward number

Patient ID number

Admission date

Contact person *

Contact person's phone number *

Referrer information

Given name *

Family name *

Provider qualification

Provider number

If other qualification, please enter here *

I would like to be kept informed by *

EmailLetterPhoneFax

Hospital/Practice phone number *

Hospital/Practice fax number

Hospital/Practice name

Please provide your email to receive a copy of this referral submission *

Practice Address *

Street address *

City *

State *

Postcode *

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 *

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

Patient Information

Given name *

Family name *

Date of Birth *

Medicare number *

Medicare Reference Number

Medicare Expiry

Patient phone number *

Patient email

Patient address *

City *

State *

Postcode *

Does the patient have an Enduring Power of Attorney *

YesNo

If yes, please provide name / relationship and phone number:

Name

EPOA Contact Number

Relationship

Patient Next of Kin

Name *

Relationship *

Contact number *

Patient GP Details

Name *

Practice Phone Number *

GP Practice *

Funding source

Private Health Fund *

Health fund policy number *

DVA number *

Please select card

White CardGold Card

Workers compensation claim number

Insurer name

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 *

Diagnosis

Patient goals *

Current mobility *

Past medical history *

If other rehabilitation care, please specify *

Do you have a preferred specialist for the private apppointment?

If other support required, please specify *

Upload referral letter, if needed

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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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