Templates for General Practice 

The following templates are for General Practice to download into their CIS.

Please access the relevant instruction sheets for information on how to import these templates to your program of choice:


Care Partnership – Diabetes

Template

Date Effective

Best Practice

Medical Director
Patient Enrolment & Consent Form November 2022

Respiratory Clinics

Template

Date Effective

Word Doc

PDF

Best Practice

Medical Director
Respiratory Clinics                                                                              May 2020 PDF

NSW Templates

Template

Date Effective

Best Practice

Medical Director
Death Certificate (NSW)                                                                              June 2019
DVA Referral January 2021

WNSW PHN Region-wide Templates

Template

Date Effective

Best Practice

Medical Director
Strong Minds Western - GP Referral and Mental Health Treatment Plan February 2020
Early Childhood Intervention Intake and Consent Form                                  April 2020
COPD Action Plan                                        PDF September 2020
RFDS SE Alcohol & Other Drugs Outreach May 2021 n/a

WNSW LHD Templates

Template

Location

Date Effective

Best Practice

Medical Director
LHD Geriatric Medicine Clinic Referral Form Western NSW LHD March 2019
LHD Lung Cancer Fast Track Clinical Referral Western NSW LHD May 2019
LHD Planned Care for Better Health Western NSW LHD November 2022

Information
LHD Alcohol & Other Drugs Service Western NSW LHD May 2021 n/a
LHD Movement Disorders Coordinator Western NSW LHD July 2022
LHD Bathurst High-Risk Foot Referral Bathurst November 2019
Bathurst After Hours Medical Service - Patient Form for RACF Visits Bathurst February 2018
LHD Dubbo Public Eye Clinic Dubbo April 2020
PRP Imaging Referral Dubbo April 2020
LHD Dubbo Fast Track Resp. Outpatient Clinic Dubbo January 2020
LHD Dubbo Respiratory LFT Referral Dubbo January 2020
Diabetes Shared Care Plan Template (Dubbo Diabetes Project)  Dubbo June 2017
Dubbo After Hours Medical Service - Patient Form for RACF Visits  Dubbo February 2018
LHD Dubbo High-Risk Foot Service Referral Form Dubbo October 2018
LHD Dubbo Neurophysiology Ambulatory Care Dubbo July 2018
Lourdes Hospital Hydrotherapy Referral Dubbo July 2018
Lourdes Hospital Pre-Admission Referral Dubbo July 2018
Orana Mall Sleep Study Referral Form Dubbo October 2019
LHD Dubbo Neurophysiology Study Referral Dubbo May 2020
LHD Dubbo Direct Access Scopes Dubbo May 2020
LHD Dubbo HITH PICC Dubbo June 2020
LHD Dubbo Orthopaedic Dubbo October 2020
LHD Orange Referral positive FBOT for NBCSP Orange January 2020
Orange Liver Clinic Referral Orange August 2020
LHD Orange Colonoscopy Referral for Positive Faecal Occult Blood Test Orange February 2018
General Paediatrics at Orange Paediatric Clinic Referral Orange April 2020
LHD Orange Iron Fusion Orange October 2020
LHD Orange Ambulatory Care Orange October 2020

Far West LHD Templates

Template

Date Effective

Best Practice

Medical Director
Far West Referral to Outpatient Clinic                November 2019
Greenwich Far West Pain Clinic Referral Form August 2021
Greenwich Far West Pain Clinic Questionnaire May 2020
Greenwich Far West Pain Clinic Follow-Up May 2020
Far West Prostate Cancer Nurse Specialist May 2021 n/a

Other Referral Forms

Template

Patient Referral Form

GP Referral Instructions
Pink Angels                                                                             PATIENT REFERRAL FORM  GP REFERRAL INSTRUCTIONS
Guide Dogs NSW/ACT PATIENT REFERRAL FORM

Referral form for Group Allied Health Services under Medicare
for patients with type 2 diabetes

 Patient Referral Form