Dubbo Hospital Respiratory Outpatient Clinic
170 Myall St DUBBO NSW 2830
Phone:  (02)6809 6095  
Fax: (02) 6809 7270
ARGUS: WNSWLHD-ccdubsmc@health.nsw.gov.au		
FAST TRACK REFERRAL 
ALL REFERRALS ARE SEEN WITHIN TWO WEEKS

Respiratory Physician Preference:    <<Respiratory Physician Patient would like to see? >>

Requesting Doctor
Date of Referral: <<Miscellaneous:Date>>	Referral Period   <<Referral Period in months?>>       months	
Doctors Name: <<Doctor:Name>>	
Doctors Address:<<Practice:Address>>	
Phone: <<Practice:Phone>>                             Fax: <<Practice:Fax>>	
Doctors Provider No: <<Doctor:Provider Number>>	
Signature: 	

Patient Details

Patient Name: <<Patient Demographics:Full Name>>                            DOB: <<Patient Demographics:DOB>>	
Patient Address: <<Patient Demographics:Full Address>>	
Patient Home Phone: <<Patient Demographics:Phone (Home)>>
Patient Mobile: <<Patient Demographics:Phone (Mobile)>>	
Medicare No: <<Patient Demographics:Medicare Number>>    Exp Date: <<Patient Demographics:Medicare Expiry Date>>	
DVA No: <<Patient Demographics:DVA Number>>
Private Health Insurance No: <<Patient Demographics:Health Insurance>>	

Please ensure 
•	All patients require a staging CT [CT chest and abdomen with contrast] prior to review in the FT clinic. Please make sure imaging is available for review at the FT clinic.
•	Please do not arrange CT guided biopsy of suspicious lesions/pleural fluid drainage until review by a Specialist  in the FastTrack clinic
•	Please do not mention “CANCER” - [shadow on CXR/CT hence the referral] 

Other Test Completed:     CXR - <<CXR test completed?>>          CT - <<CT scan completed?>>                               Pathology - <<Pathology completed?>>              PET - <<PET scan completed?>>

Please ensure that all supporting documents are attached and fax completed form to the Respiratory Outpatient Clinic on 02 6809 7270. The patient will be contacted to arrange for further tests if required and an early appointment.

Indications for referral
Any of the following unexplained persistent symptoms and signs lasting more than 3 weeks (or less than 3 weeks in people with known risk factors): Please mark with an X
	New or changed cough		Signs of pleural effusion	
	Chest and/or shoulder pain			Unresolved chest infection	
	Unexplained dyspnoea		Hoarseness	
	Weight loss/ loss of appetite		Finger Clubbing	
	Cervical and/or supraclavicular lymphadenopathy 		Abnormal chest signs	
	Features suggestive of metastasis from a lung cancer (for example, in brain, bone, liver or skin)		Haemoptysis	

FAST TRACK REFERRAL
Co-morbidities present          <<Co-morbidities present in patient?>>

WHO preformance Status (please select)
<<Patient's WHO performance Status - please select>>

On antiplatelet therapy         <<Is patient on antiplatelet therapy?>>   

On anticoagulant therapy       <<Is patient on anticoagulant therapy?>>    

Presenting Problem:
<<What's patient presenting Problem?>>