Patient details
Name : <PtName>       Date of Birth: <PtDoB>
Address:
 <PtAddress> 
Phone (Home)	<PtPhoneH>	 Phone (Mobile)  <PtPhoneMob>
Email:	<PtEmail>
Medicare Number: <PtMCNo>  Position on card (Number):  <PtMCLine>  

Medicare Card Expiry Date: <PtMCNo>      Aboriginal and/or Torres Strait Islander: <PtEthnicity>

Referring Doctor/Nurse Practitioner details
Name: <DrName>	      Provider Number: <DrProviderNo>
Address:
  <UsrAddress> 
Phone: 	<UsrPhone>	            Fax:  <UsrFax>
Email:  <PracEmail>  
Date of referral:  <TodaysDate>	                    Signature: ______________________________________
Referral details
Location of pain:  <Location of patient's pain?>
Cause of pain (Underlying pathology if known):  <Cause of pain (underlying pathology if known)?> 

Current pain medications including dose:  <Current pain medications including dose?>
* PLEASE LIST in detail which medications have been trialled, up to what dose, timeframe of each medication and reason/s for stopping: (Add in details manually)
Medication Name	Dose	Timeframe of Medication	Reason/s for stopping	

				

Allergies:  <Allergies/Adverse Reactions>

Psychiatric History:  <Psychiatric History?>

What are your reasons for referring this patient?  <What are your reasons for referring this patient?>