Patient details
Name : <<Patient Demographics:Full Name>>       Date of Birth: <<Patient Demographics:DOB>>
Address:
 <<Patient Demographics:Full Address>> 
Phone (Home)	<<Patient Demographics:Phone (Home)>>	 Phone (Mobile)  <<Patient Demographics:Phone (Mobile)>>
Email:	<<Patient Demographics:E-mail>>
Medicare Number: <<Patient Demographics:Medicare Number>>  Position on card (Number):  <<Position on Medicare card?>>   

Medicare Card Expiry Date: <<Patient Demographics:Medicare Expiry Date>>      Aboriginal and/or Torres Strait Islander: <<Patient Demographics:Ethnicity>>

Referring Doctor/Nurse Practitioner details
Name: <<Doctor:Name>>	      Provider Number: <<Doctor:Provider Number>>
Address:
  <<Practice:Address>> 
Phone: 	<<Practice:Phone>>	            Fax:  <<Practice:Fax>>
Email:  <<Practice email address>>  
Date of referral:  <<Miscellaneous:Date>>	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:  <<Clinical Details:Allergies/Adverse Reactions>>

Psychiatric History:  <<Psychiatric History?>>

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