Health
 Western NSW
                Local Health District	Family Name: <<Patient Demographics:Surname>>               MRN:
Given Name: <<Patient Demographics:First Name>>                 Sex: <<Patient Demographics:Gender>>
DOB:  <<Patient Demographics:DOB>>                                          M.O. 	
Facility: 	  Address:        
<<Patient Demographics:Full Address>>                                      	
DUBBO AMBULATORY/HOSPITAL IN THE HOME/PICC REFERRAL	 Location / Ward
 COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE	

Date of Referral:
<<Miscellaneous:Date>>	Request Start Date: 
<<Request Start Date?>>	Proposed Lenght of Treatment:
<<Proposed Lenght of Treatment?>>	ALLERGIES:
<<Clinical Details:Allergies/Adverse Reactions>>	
Patient’s Contact Phone: (H)   <<Patient Demographics:Phone (Home)>>        (mob) <<Patient Demographics:Phone (Mobile)>>	
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?>>
<<Summary:Investigation Results (Selected)>>
<<Clinical Details:History List>>
<<Clinical Details:Medication List>>

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:   <<Doctor:Name>>                         
Practice Details:  
<<Practice:Name>>
<<Practice:Address>>
Phone: <<Practice:Phone>>              Fax:  <<Practice:Fax>>
	
 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