Healt Health
           Western NSW
                 Local Health District	Family Name: <PtSurname>               MRN:
Given Name: <PtFirstName>                 Sex: <PtSex>
DOB:  <PtDoB>                                          M.O. 	
Facility: 	  Address:        
<PtAddress>                                      	
DUBBO AMBULATORY/HOSPITAL IN THE HOME/PICC REFERRAL	 Location / Ward
 COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE	

Date of Referral:
<TodaysDate>	Request Start Date: 
<Request Start Date?>	Proposed Lenght of Treatment:
<Proposed Lenght of Treatment?>	
ALLERGIES:
<Reactions>	
Patient’s Contact Phone: (H)   <PtPhoneH>        (mob) <PtPhoneMob>	
Patient’s Person for Notification:
Name:  <Patient’s Person for Notification?>           Relationship to patient:     <Relationship to patient?>                  Phone Number:  <Patient’s Person for Notification phone number?>
	
DIAGNOSIS: 
<Patient's Diagnosis?>
	
Presenting Problem/Planned Procedure: 
<Presenting Problem / Planned Procedure>

Tests Required:
<Tests Required?>
	
Relevant Clinical Details: (e.g.  pathology results, hospitalisation, co-morbidities)
<Relevant Clinical Details?>
<SelectedPMH>
<SelectedRx>

	
Peripherally Inserted Central Catheter (PICC)/MIDLINE REQUEST ONLY

Consent Form Completed:    <Consent Form Completed? Prior to PICC insertion>  (Must be completed by Referring team PRIOR to PICC insertion)

Coagulation Status: Is the patient receiving?  Warfarin:    <Is patient receiving Warfarin?>      INR:     <Patient INR?>
                                                                                   Heparin:     <Is patient receiving Heparin?>      APTT:   <Patient APPT?>
                                                                                   Other:        <Other?>
Does patient have a Coagulopathy?       <Does patient have Coagulopathy?>
	
Signature of Referrer:                                                     Print Name:   <DrName>                         
Practice Details:  
<Practice>
<UsrAddress>
Phone: <UsrPhone>              Fax:  <UsrFax>
	
 PLEASE FAX ALL ACU, HiTH and PICC  REFERRALS to 6809 7252
Please call to organise appointment times HiTH RN 0458 274 647                  or HiTH/Amb Care Doctor 0436 635 178 or 6809 6000