ࡱ> ` Bbjbjss 2FP8lVDG zzzz&PvTrtttttt$7!h#tiv@"vvzzh vRzFRzrvr$""z ۢLd 0G $b,$$(vvvvvvvvvvG vvvv REFERRAL FORMOutpatient Department Use Only: Clinic: Date & Time:Campus Required:Outpatient Department (OPD)Emergency Department (ED) FORMCHECKBOX  Angliss Hospital OPD - Allied Health OnlyPh: 9764 6150 Fax: 9764 6149Nurse: 9764 6246 Doctor: 9759 1983 FORMCHECKBOX  Box Hill HospitalPh: 9895 3353 Fax: 9895 4852Nurse: 9895 3219 Doctor: 9895 3195 FORMCHECKBOX  Maroondah HospitalPh: 9871 3370 Fax: 9871 3202Nurse: 9871 3563 Doctor: 9871 3562Visit www.easternhealth.org.au to view outpatient services available, current expected waiting time for appointment and consultants in attendance.Date:  TIME \@ "dddd, d MMMM yyyy" Wednesday, 1 November 2006 Page:  FORMTEXT       of  FORMTEXT       Department Required:  FORMCHECKBOX  Emergency  FORMCHECKBOX  Outpatient: Please call ahead to notify Specialty:  FORMTEXT state clinic required ... complete or delete Consultant:  FORMTEXT include name (Medicare compliance) ... complete or delete Timeframe:  FORMCHECKBOX  Urgent (1-2 weeks)  FORMCHECKBOX  Intermediate (>4 weeks)  FORMCHECKBOX  Routine If urgent state why:  FORMTEXT state why urgent ... complete or delete Referral Duration:  FORMDROPDOWN  Patient Details: Full Name:  FORMTEXT       Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female DOB:  FORMTEXT       Age:  FORMTEXT       Address:  FORMTEXT       Post Code:  FORMTEXT      AH Phone:  FORMTEXT       BH Phone:  FORMTEXT       Email:  FORMTEXT       Mobile:  FORMTEXT       Medicare #:  FORMTEXT       Health Insurance:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Interpreter:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Language Required:  FORMTEXT       Reason for ReferIou    ' ³³£xgx[xMxh,{CJOJQJ^JaJh,{CJOJQJ^J hYhYCJ OJQJ^JaJ h,{CJOJQJ^J%juh,{CJOJQJU^Jh,{CJOJQJ^Jjh,{CJOJQJU^JhY5CJOJQJ\^Jh,{5CJOJQJ\^Jh,{5CJ0OJQJ\^Jh,{5CJ OJQJ\^Jjh,{CJ OJQJU^J019:;H$-DIfM ^$$-DIfM ^a$ $ !$Ifa$  !$If7^BBBHIZvypp $$Ifa$$Ifkds$$IflF Ee)D 6    4 lap  4^kdu$$IfTlF e)8,$6    4 laT $$Ifa$$If^kdt$$IfTlF e)8,$6    4 laT' ( ) *   " $ ^ ` бģĔmaQa>Q%jfxh,{CJOJQJU^Jjh,{CJOJQJU^Jh,{CJOJQJ^J'hY5CJOJQJ\^JmHnHu%jh,{5CJOJQJU\^Jh,{5CJOJQJ\^Jh,{CJOJQJ^JaJ%jwh,{CJOJQJU^Jh,{CJOJQJ^Jh,{CJOJQJ^Jjh,{CJOJQJU^J%jvh,{CJOJQJU^J < ^ ^kdv$$IfTlF e)8,$6    4 laT $$Ifa$$If    M ]USJC ( (< Bx;kdw$$IfTl4e)64 laf4T $$Ifa$^kdzw$$IfTlF e)8,$6    4 laT    " # $ % . / 0 > ? @ A L M h i s t u  λΫ΀q^qRqh,{CJ OJQJ^J%jyh,{CJOJQJU^Jh,{5CJOJQJ\^J%jRyh,{CJOJQJU^J.jh,{CJOJQJU^JmHnHsH uh,{5>*CJOJQJ\^J%jxh,{CJOJQJU^Jh,{CJOJQJ^Jjh,{CJOJQJU^J*jh,{CJOJQJU^JmHnHu        ! 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