MEDICAL OBJECTS ID: HM4101000R8
														Healthlink EDI: materref

To ensure a timely appointment, complete all sections of this form. Incomplete forms will be returned for completion. 

Patient Details:
Re: <PtFullName>
Name:	<PtPrefName>
Surname:	<PtSurname>
Given Names:	<PtFirstName> <PtMidName>
Parent/Guardian's full name: <Parent/Guardian's full name>
Date of Birth:	<PtDoB>	Sex: <PtSex>
Patients Address:	<PtAddress>
Home Phone No.:	<PtPhoneH>
Mobile Phone No.:	<PtPhoneMob>
Interpreter Required?:	<Interpreter Required?>	Language: <Language?>
Aboriginal / Torres Strait Islander origin: <Aboriginal / Torres Strait Islander origin?>

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Medicare Eligible?:	<Medicare Eligible?>
Medicare No.:	<PtMCNo>
Private Health Insurance: <Private Health Insurance>
NDIS Participant: <NDIS Participant>	If YES NDIS No.: <If YES, NDIS No>
Compensable Status:	<Compensable Status> 	Other Compensable: <Other Compensable>

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Reason for Referral: Please include all the essential condition-specific information outlined in standard referral guidelines, located at www.materonline.org.au

Provisional Diagnosis / Presenting Conditions / What question/s are you asking of your specialist colleagues:
<Provisional Diagnosis / Presenting Condition>

Relevant Clinical History / Examination:
<Visits>

<SelectedPMH>

My patient's condition corresponds with the following urgency category and associated clinically recommended waiting time as per Referral Criteria @ Mater Online:
<Referral guidelines indicate the following urgency>

Allergies:
<Reactions>

Medications:
<SelectedRx>

Relevant Investigations:
<Ix>

What additional documents have been faxed or sent?: 
<What additional documents have been faxed/sent>

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Referral Details: To reduce referral wait times, this referral may be shared with other Specialists

Referred to:	<Referred to (This is a mandatory field)>
Other:	<Other clinician (refer to)>
Date of Referral:	<TodaysDate>
Continuation Referral:	<Continuation Referral?>
Updated Referral/Additional Information: <Updated Referrall / Additional Information>
Duration of Referral:	<Duration of referral>
This patient may be eligible for a Telehealth consult: <This patient may be eligible for a telehealth consultation?>
Is the referring practitioner to be involved in the telehealth consult: <Is the referring practitioner to be involved in the telehealth consultation?>
Referring Clinician:	<DrName>	Provider No.: <DrProviderNo>
Practice Name: <Practice>
Address: <DrAddress>
Phone: 	<DrPhone>	Fax: <DrFax>
Email: 	<DrEmail>

Signed:	<DrName>